198602212-10-12-2022-28-AS-BPEA-CK5VKW-20221012163102

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602212
Report Date: 10/12/2022
Date Signed: 10/12/2022 04:31:10 PM

Document Has Been Signed on 10/12/2022 04:31 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	BUNGALOW		FACILITY NUMBER:	198602212
ADMINISTRATOR:	RAMIREZ, CARINA		FACILITY TYPE:	740
ADDRESS:	1314 WOODBURY ROAD		TELEPHONE:	(626) 296-6977
CITY:	PASADENA	STATE: CA	ZIP CODE:	91104
CAPACITY: 6		CENSUS: 6	DATE:	10/12/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:28 PM
MET WITH:	Administrator		TIME COMPLETED:	05:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced annual inspection focusing on the Infection Control Domain. LPA Pena was greeted by Caregiver Lourdes Cruz and discussed the purpose of today's visit. Shortly thereafter, the House Manager, Stacy Lopez arrived. The facility cares for the elderly and is approved to have six (6) ambulatory of which four (4) may be non ambulatory and one (1) may be bedridden. There are currently six (6) residents living in the home of which two (2) are non ambulatory. This single-story home contains four (4) bedrooms, three (3) bathrooms, a living room, kitchen, dining area, backyard, and detached garage. At 2:50pm, LPA Pena and House Manager toured the facility. The following was observed/inspected: The facility had a universal entrance screening area; sign-in and temperature logs were maintained. However, none of the caregivers performed covid-19 screening to the LPA. COVID-19 signage was placed in several areas of the facility including the front entrance. All areas were found to be clean and in good repair. Facility maintained a 30-day supply of PPE to include masks, gowns, and face shields located in the detached garage. Staff wore face masks consistently throughout the shift. House Manager stated that the Infection Control Plan will be submitted to CCLD no later than 10/19/2022. All resident bedrooms were toured. Each room contained required furniture including bed, dresser, night stand, lamp, chair, and closet. Two (2) of the bedrooms have working auditory chime. All beds contained the required linens including mattress cover, fitted sheet, flat sheet, blanket, and comforter.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

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 10/12/2022 04:31 PM - It Cannot Be Edited

Created By: Bennette Pena On 10/12/2022 at 04:04 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: BUNGALOW	FACILITY NUMBER: 198602212
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(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 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on (observation), the licensee did not comply with the section cited above in [which the hot water temperature readings for bathrooms #2 and #3 read at 136.1 and 141.2 respectively which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/13/2022
	Plan of Correction
1 2 3 4	The Administrator/House Manager will fix the hot water temperature in both bathrooms immediately and will send the 7 days hot water log via email to LPA by 10/19/2022.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

David Sicairos

LICENSING EVALUATOR NAME:

Bennette Pena

LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BUNGALOW	FACILITY NUMBER: 198602212
	VISIT DATE: 10/12/2022

NARRATIVE

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Bathrooms are clean and operational and were observed to be within Title 22 regulations. Toilets and water faucets worked properly. Shower was free of mold/mildew, adequate lighting, and sufficient toiletries are accessible to clients. Bathrooms contained supplies including liquid soap, toilet paper, and paper towels.
At 3:09pm, kitchen was inspected and LPA observed sufficient perishable and non-perishable food. All the appliances are clean and are operating properly. There is a 2^nd refrigerator/freezer in the detached garage with additional food supplies.
Knives, other sharp items, hazardous toxins and/or items are stored and locked in a kitchen cabinet under the sink which are inaccessible to clients.
At 3:12pm, hot water temperature was checked and read 119.6 deg. F in bathroom #1, 136.1 deg. F in bathroom #2, 141.2 deg. F in bathroom #3 and 111.6 deg. F in kitchen sink. LPA re-checked the hot water temperature at 4:00pm in bathrooms #2 and #3, but reading still showed over 120 deg F.
Laundry room is located outside the home and kept locked at all times.
Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in good repair and Facility temperature was comfortable and read at 80 deg. F.
First aid kit is fully stocked with manual, smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present.
All clients medications were reviewed and LPA observed that medications are stored, locked and inaccessible to clients. Medications are documented properly and given as prescribed.
Staff and clients are fully vaccinated with booster.
Two (2) fire extinguishers were observed to be fully charged and last serviced on March 10, 2022. One (1) is located in the kitchen/dining area and the other one is in the laundry room.

NOTE: House Manager stated that the Administrator Linda Morales will update the Infection Control Plan to include Monkeypox and will send it to CCLD by 10/19/2022.

Pursuant to Title 22, deficiency was cited on the attached 809D and and Technical Assistance were issued. An exit interview was conducted and a copy of this report was provided to the House Manager, Stacy Lopez.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

LIC809 (FAS) - (06/04)

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