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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602557
Report Date: 09/30/2021
Date Signed: 09/30/2021 04:48:21 PM

Document Has Been Signed on 09/30/2021 04:48 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ALONDRA GUEST HOMEFACILITY NUMBER:
198602557
ADMINISTRATOR:VILLAFLORES, LOURDESFACILITY TYPE:
740
ADDRESS:11849 ALONDRA BLVDTELEPHONE:
(562) 863-7630
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 6CENSUS: 5DATE:
09/30/2021
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
02:32 PM
MET WITH:Gloria MendozaTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Nicol Wesley conducted an unannounced Annual Continuation inspection at the facility and met with caregiver Gloria Mendoza and explained the purpose for todays visit. Prior to the visit LPA Wesley conducted a risk assessment for on-site inspections. The facility phone number is 562 863 7630.

The facility consist of six bedrooms(#1, #4 and #6 are for staff), three bathrooms,(one in bedroom #2, and #5), living room, dining room, kitchen and enclosed outdoor patio located in the back yard with washer and dryer, attached garage(storage and overflow of food).

On 09/02/21 LPA conducted a complete tour of the facility, and observe the supply of food. Resident medications, and medication are locked in staff room #6. The smoke detectors/carbon monoxide detector are operable. The Fire alarm system has a pull switch, and there is one fire extinguisher located by the kitchen/dining room area. The mitigation plan was approved on 04/09/2021.

During todays visit the Infection control domain was used and the following areas were observed/inspected: The facility has postings at the front entrance, bathrooms, and throughout the facility. A Pre screening area with thermometer, hand sanitizing gel and masks were located at the front entrance of the facility. The water temperature was tested and measured at 120 degrees F.

The following deficiencies were cited according to California Code of Regulations, Title 22, Division 6, Chapter 8. Appeal rights given, and a copy of the LIC 809 was given during the exit interview.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Nicol Wesley
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2021
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 09/30/2021 04:48 PM - It Cannot Be Edited


Created By: Nicol Wesley On 09/30/2021 at 03:37 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: ALONDRA GUEST HOME
FACILITY NUMBER: 198602557

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/30/2021
Section Cited
CCR
87303(a)

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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. This requirement has not been met as evidence by: During the visit on 09/02/21 and 09/30/21
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The Administrator shall have all of the items removed by poc date 10/30/21, and submit LIC 9098(proof of correction) to LPA Wesley via US mail or fax.
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LPA observed bedroom #1 bedroom #4 to be in need of cleaning/organizing, the window seals in the bedroom windows to be dirty and in need of cleaning which poses a potential health and safety risk for the residents in care.
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CCR

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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:Rebecca Orendain
LICENSING EVALUATOR NAME:Nicol Wesley
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2021


LIC809 (FAS) - (06/04)
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