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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602212
Report Date: 10/20/2023
Date Signed: 10/20/2023 02:48:01 PM

Document Has Been Signed on 10/20/2023 02:48 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:BUNGALOWFACILITY NUMBER:
198602212
ADMINISTRATOR:RAMIREZ, CARINAFACILITY TYPE:
740
ADDRESS:1314 WOODBURY ROADTELEPHONE:
(626) 296-6977
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 6CENSUS: 6DATE:
10/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:22 AM
MET WITH:Linda MoralesTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required 1-year Visit on 10/20/2023 at 08:22 am. LPA was met by Caregiver, Lourdes Cruz and explained the purpose of the visit. The facility is licensed to serve six (6) residents over the age of 60, of which four (4) may be non-ambulatory and one (1) bedridden.

LPA OBSERVATIONS: The facility is a single-story building located in a residential neighborhood with five (5) resident bedrooms, three (3) bathrooms, kitchen, dining room, living room, front yard, backyard, and detached garage.

Front Yard: Was clean and well maintained. No hazards were observed.

Kitchen: LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located in kitchen cabinet, to be inaccessible to six (6) out of six (6) residents in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants located in kitchen cabinet, to be inaccessible to six (6) out of six (6) residents in care. Kitchen sink water temperature was measured at 115.0 degrees F. Kitchen appliances were observed to be clean and in working order.

Dining Room/Living room/: Dining room was observed to be clean and contained one table with plenty of seating. Living room was observed to have plenty of seating and lighting. LPA Ramirez observed private caregiver#1 feeding resident#2 (R2) breakfast at dining room table. LPA Ramirez observed Staff#3 (S3) providing care and supervision to residents at the dining room table.

Linen Closet: Contained plenty linens, towels, hygiene products, and extra PPE supplies.



Resident Rooms 1 - 5: LPA Ramirez observed all five (5) resident bedrooms to contain required furnishings, lighting, and linens.

Bathrooms: Signs promoting hand washing were observed in all bathrooms. Water temperature in all three (3) resident bathrooms were within 105- 120 degrees F. Bathrooms were observed to be clean and well stocked.

See 809-C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2023
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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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: 10/20/2023
NARRATIVE
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Emergency Drills: Last documented drill was conducted on 9/30/23.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide in hallways and smoke detectors were observed to be operable.

Staff Personnel Files: Staff files are maintained at facility. LPA Ramirez reviewed staff files for six (6) staff. LPA Ramirez observed Administrator’s certificate for Linda Morales with an expiration date of 01/03/2025. Staff#1 (S1) personnel record could not be located. Staff #3(S3) and private caregiver #1 did not have proof of fingerprint clearance nor personnel record to review. LPA Ramirez will issue civil penalties of $200 for violation of criminal clearance.

Resident Files: Six (6) resident files were reviewed.

Liability Insurance & Infection Control Plan: Facility has current liability insurance on file. LPA Ramirez observed updated infection control plan.



Deficiencies are being cited and civil penalties. Exit interview was conducted with Administrator Morales and a copy of this report, LIC 809-D, and appeals rights was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/20/2023 02:48 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 10/20/2023 at 12:43 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: 10/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, Staff#1 (S1) personnel record was missing and could not be located during visit per licensee,the licensee did not comply with the section cited above in 6 out of 6 residents, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/27/2023
Plan of Correction
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Licensee will recreate documents for personnel records per title 22 and send LPA Ramirez a copy via email.
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review), Staff#1 (S1) was missing health screening, the licensee did not comply with the section cited above in 6 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2023
Plan of Correction
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Licensee will have S1 complete new health screening and send to LPA via email.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/20/2023 02:48 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 10/20/2023 at 01:33 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: 10/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
87355
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Staff #3 (S3) and private caregiver #1 were observed to be providing care and supervision to residents. Licensee could not provide proof of fingerprint clearance.
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 6 out of 6 residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2023
Plan of Correction
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Licensee will remove staff#3 (S3) and private caregiver#1 until they have fingerprint clearance. Licensee will certify via email to LPA Ramirez, private caregiver will not provide care and supervision unless they have been fingerprint cleared.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2023


LIC809 (FAS) - (06/04)
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