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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602174
Report Date: 08/04/2022
Date Signed: 08/04/2022 11:56:43 AM

Document Has Been Signed on 08/04/2022 11:56 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ALLEN'S PALM COVE CERRITOSFACILITY NUMBER:
198602174
ADMINISTRATOR:DIMAANO, EUPHROSYNEFACILITY TYPE:
740
ADDRESS:18714 KINGS ROW AVETELEPHONE:
(562) 866-3585
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 6CENSUS: 3DATE:
08/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Peter Nora; AdministratorTIME COMPLETED:
12:11 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Sicairos conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPA met with Administrator Peter Nora and explained the reason for the visit. Physical Plant was toured, medications were reviewed, and food supply was inspected.

The following was observed/inspected:
  • LPA and Administrator toured the home and observed: (4) bedrooms, (2) bathrooms, living room, activity room, kitchen, dining room, and attached garage. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction. The water temperature was tested in bathroom #1 in the hallway and measured at 125F which is above the required 105F - 120F degrees. Administrator lowered the water temperature during the visit. Grab bars and non-skid mats were observed in the bathrooms. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have sufficient closet space. Resident beds have the required linen and the linen is in good condition. Smoke detectors were observed throughout the facility and were tested and operable during the visit. There is a carbon monoxide detector located in the hallway of the home. There is a fire extinguisher located near the kitchen which is fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked in a kitchen drawer and are inaccessible to residents. Cleaning supplies and disinfectants are locked under the sink and are inaccessible to the residents. First Aid kit was fully stocked with current manual.
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • Staff were observed wearing masks and screening visitors at entry.
  • Sufficient supply of 2 days perishable & 7 days non-perishable foods were observed.
  • (3) out of the (3) resident medications were reviewed. Medications are centrally stored in a cabinet in the kitchen. Medications are documented properly and given as prescribed.
  • Staff and Resident files were not reviewed during today's visit.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during the visit is documented on 809D. Exit interview held and a copy of the report along with appeal rights were provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: David Sicairos
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/04/2022 11:56 AM - It Cannot Be Edited


Created By: David Sicairos On 08/04/2022 at 11:11 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ALLEN'S PALM COVE CERRITOS

FACILITY NUMBER: 198602174

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 08/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
(e) Water supplies and plumbing fixtures shall be maintained as follows:

(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).


This requirement is not met as evidenced by:
Deficient Practice Statement
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During physical plant tour, LPA measured water temperature in bathroom #1 located in the hallway which measured at 125F which poses an immediate health, safety or personal rights risk to persons in care. Water temperature was lowered by the Administrator during today's visit.
POC Due Date: 08/05/2022
Plan of Correction
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Administrator/Licensee to ensure facility water temperature meets Title 22 Regulations. Administrator/Licensee to monitor water temperature for the next 24 hours and submit water log to CCL by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stefanie Coronel
LICENSING EVALUATOR NAME:David Sicairos
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022


LIC809 (FAS) - (06/04)
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