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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602174
Report Date: 08/24/2022
Date Signed: 08/29/2022 03:27:51 PM

Document Has Been Signed on 08/29/2022 03:27 PM - 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: 4DATE:
08/24/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
06:00 PM
MET WITH:Euphrosyne Dimaano and Peter NoraTIME COMPLETED:
09:35 PM
NARRATIVE
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Regional Manager(s) (RM) Angela Kendrick and Benita Yates conducted a case management visit for the purpose of conducting a health and safety check. Licensing Program Analyst (LPA) Jose Villalobos attended the visit virtually. RM's Angela and Benita were met by staff Rebecca Blake. Administrators Euphrosyne Dimaano and Peter Nora arrived shortly after

Licensing received information regarding possible health and safety concerns involving residents of the facility. During the visit the following was observed:
  • pads with urine and feces in Resident #1s (R1) bedroom
  • Oxygen tank observed in Resident #2's (R2) room without required signs being posted



Deficiencies cited under California Code of Regulations, Title 22, Division 6 and Chapter 1, documented on LIC 809D.

Exit interview was conducted, Appeals right and a copy of this report were provided via email for signature.


SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 08/29/2022 03:27 PM - It Cannot Be Edited


Created By: Jose Villalobos On 08/24/2022 at 09:05 PM
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: 08/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/25/2022
Section Cited
CCR
87618(b)(3)(B)

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Oxygen Administration - Gas and Liquid. In addition to Section 87611(b), the licensee shall be responsible for the following:(3)Ensuring that the use of oxygen equipment meets the following requirements: (B) "No Smoking-Oxygen in Use" signs shall be posted in the appropriate areas.
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Administrator Shall place appropriate signs needed and place on R2's door.

*** Citation cleared at the time of visit. LPA observed staff place required sign in a visable area.
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This Requirement is not met as evidenced by;
Resident #2 had an oxygen machine and a "No Smoking-Oxygen in Use" sign was not posted in the appropriate area.

This poses and immediate health, safety or personal rights risk to persons in care.
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Type B
09/02/2022
Section Cited
CCR87303(a)

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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Staff to clean R1's room and provide proof to licensing by POC due date.

*** Citation was cleared at the time of the visit as LPA oberved staff clean R1's room of feces and urine.
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This requirement was not met as evidenced by: Residents #1's room had feces and urine on the floor.

This poses a potential health and safety risk for residents under care and sueprvision.
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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:Fernando Fierros
LICENSING EVALUATOR NAME:Jose Villalobos
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2022


LIC809 (FAS) - (06/04)
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