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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602212
Report Date: 09/27/2024
Date Signed: 09/27/2024 03:04:13 PM

Document Has Been Signed on 09/27/2024 03:04 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/
DIRECTOR:		RAMIREZ, CARINAFACILITY TYPE:
740
ADDRESS:1314 WOODBURY ROADTELEPHONE:
(626) 296-6977
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 6CENSUS: 6DATE:
09/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:33 AM
MET WITH:Stacy Santam - Manager
Linda Morales, Administrator 		TIME VISIT/
INSPECTION COMPLETED:
03:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required-1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Lourdes Cruz, Caregiver and explained the purpose of the visit. At 10:25am, Stacy Santam, Manager arrived and assisted LPA. Shortly after, Linda Morales, Administrator arrived and assisted LPA. The facility is licensed to care for six (6) elderly residents ages 60 and above, approved for (6) ambulatory of which (4) may be non ambulatory, of which (1) may be bedridden. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained. The facility has submitted a COVID-19 Mitigation Plan and the Infection Control Plan. Bathrooms are maintained in operating condition.
Operational Requirements: The Infection Control Plan was reviewed. However, the licensee cannot provide a copy of the Plan of Operation and stated that the plan is not kept and maintained in the facility. Last Fire Drill was conducted on 09/10/2024 and training is conducted with staff on a monthly basis. Liability Insurance policy is valid and expires on 10/07/2024. Facility does not handle cash resources for the residents. Facility has working signal systems in exit points, which were tested and operational.
Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood. It consists of (5) resident bedrooms, (3) bathrooms, living room with screened fireplace, kitchen, dining area, laundry area, detached garage, and backyard. Currently, there are six (6) non ambulatory residents living in the facility. The interior and exterior physical plant was inspected. Resident bedrooms were toured. Each bedroom has a smoke detector and 5 beds with 1/2 bedrail and (1) with full bed rail, linen, dresser, light, chair and sufficient closet space. Exit doors have auditory device. Backyard was inspected and has a shaded area and sitting area. Laundry area is located outside. There are no cameras in the home. LPA observed (2) fire extinguishers that were last serviced on 03/06/2024. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. Water temperature readings in (2) bathrooms measured within the required 105 - 120 degrees Fahrenheit. However the hot water reading in bathroom #3 did not go higher than 84.9 deg F.
*****REPORT CONTINUED ON LIC809-C*****
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2024
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: 09/27/2024
NARRATIVE
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Staffing: A total of nine (9) staff members including the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility.
Personnel Records/Staff Training: Reviewed files for three (3) staff. Proof of staff training, health clearance, fingerprint clearance, vaccinations and 1st Aid/CPR training are current. Administrator certificate is valid and will expire on 01/03/2025.
Resident Rights-Information: Resident personal rights are posted. Facility provides internet services to all residents and have access to the facility phone.
Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed.
Food Service: There are sufficient food supplies of 2-day perishable and 7-day non-perishable items. The food is properly stored in the refrigerator. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.
Resident Records-Incident Reports: LPA reviewed (6) resident files. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including TB and Ambulatory Status), Appraisal and Needs Services plan and Resident Personal Rights observed. Some residents do not have I.D. and Emergency Information (Face sheet), Consent for Medical Treatment, Resident Personal Property and Physician's order for 1/2 bed rails on their files.
Health Related Services: Medications were reviewed for (4) residents to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log and medication list to document medications given. Medications are administered as prescribed by the Physician. Incidental Medical Services: There is zero (0) resident with a restricted health condition.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan. Emergency Intervention: Not-Applicable.


Deficiencies cited. Exit interview and a copy of this report along with the appeal rights were provided to the Administrator/Licensee Linda Morales.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 09/27/2024 03:04 PM - It Cannot Be Edited


Created By: Bennette Pena On 09/27/2024 at 02:03 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: 09/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(a)
Plan of Operation
(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in that the licensee cannot provide copy of the Plan of Operation and stated that the plan is not kept and maintained in the facility which poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 10/11/2024
Plan of Correction
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Licensee will submit a copy of the Plan of Operation to LPA/CCL by POC due date.
Type B
Section Cited
CCR
87208(c)
Plan of Operation
(c) A licensee who accepts or retains residents diagnosed by a physician to have dementia shall include additional information in the plan of operation as specified in Section 87705(b).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview andrecord review, the licensee did not comply with the section cited above in that the licensee retains dementia residents but cannot provide prrof that the dementia plan is in place and included in the Plan of Operation which poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 10/11/2024
Plan of Correction
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Licensee agreed to send a copy of the dementia plan and ensure that the informaiton is added to the Plan of Operation to CCL/LPA by POC due date.
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: 09/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 09/27/2024 03:04 PM - It Cannot Be Edited


Created By: Bennette Pena On 09/27/2024 at 02:03 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: 09/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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
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Based on observation, the licensee did not comply with the section cited above in that the water reading in bathroom #3 did not go higher than 89.4 deg F which poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 10/11/2024
Plan of Correction
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Licensee agreed to send a hot water reading log for 7 days along with a copy of the request correspondence to the property owner to fix the water heater. These documents will be submitted to CCL/LPA by POC due date.
Type B
Section Cited
CCR
87204(a)
Limitations -Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in that the facility is providing care for 6 non ambulatory residents, but was only licensed for 4 non ambulatory residents which poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 10/11/2024
Plan of Correction
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Licensee will submit an updated physician's report for 2 residents proving ambulatory status and/or send a request to increase the number of non ambulatory residents in the facility to LPA/CCL by POC due date.
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: 09/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 09/27/2024 03:04 PM - It Cannot Be Edited


Created By: Bennette Pena On 09/27/2024 at 02:03 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: 09/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(b)
Other Provisions
(b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in which some of the staff who administer medication have not completed medication training which poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 10/11/2024
Plan of Correction
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Licensee will ensure that staff completes medication training and submit a copy of the completed medication training to CCL/LPA by POC due date.
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in which 2 of 6 residents (Residents #4-#5) did not have a written order from a physician to use 1/2 bedrail on their files which poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 10/11/2024
Plan of Correction
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Licensee will submit the physician's order for 1/2 bedrails for Residents #4-#5 to LPA/CCL by POC due date.
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: 09/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 09/27/2024 03:04 PM - It Cannot Be Edited


Created By: Bennette Pena On 09/27/2024 at 02:03 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: 09/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in that Resident #6 uses full bed rail but not under hospice care which poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 10/11/2024
Plan of Correction
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3
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Licensee agreed to send doctor's authorization for the correct postural support/bed rail order for Resident #6 to LPA/CCL by POC due date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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: 09/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024


LIC809 (FAS) - (06/04)
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