198602557-8-20-2024-28-AS-JVIS-D8BTL8-20240820144906

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602557
Report Date: 08/20/2024
Date Signed: 08/20/2024 02:49:15 PM

Document Has Been Signed on 08/20/2024 02:49 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 HOME		FACILITY NUMBER:	198602557
ADMINISTRATOR/ DIRECTOR:	VILLAFLORES, LOURDES		FACILITY TYPE:	740
ADDRESS:	11849 ALONDRA BLVD		TELEPHONE:	(562) 863-7630
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY: 6		CENSUS: 3	DATE:	08/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:15 AM
MET WITH:	Administrator Joy Villaflores		TIME VISIT/ INSPECTION COMPLETED:	03:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with administrator Joy Villaflores and the purpose of the visit was explained.

The following CARE tools domains were utilized during the inspection.

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. Visitors are no longer screened for COVID-19 or required to sign in. The facility has an Infection Control Plan and COVID-19 Mitigation Plan.

Physical Plant/Environment Safety: The facility is a single-story house located in a residential neighborhood. Facility has three resident rooms; room #2 #3 and #5. Resident room #5 contains a private bathroom, three staff rooms; room #1, #4 and #6. Room #4 contains a private restroom for staff. There is (1) common bathroom for all residents to use. Total bathrooms is (3). Facility has a dining room, a kitchen, a front and back yard patio area which held a storage shed and the facility’s washing and drying machines, and an attached garage which held the facility’s emergency food supply and cleaning supplies. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Water temperatures measured within Title 22 requirements. The facility has one (1) fully charged fire extinguisher.

Operational Requirements: The facility has a Dementia Waiver on file. A Hospice Waiver for up to (1) Resident is approved. Facility as an approved fire clearance to serve total of six (6) residents age 60+ of which four (4) may be non-ambulatory. Required Liability Insurance is in place. A surety bond is not applicable. Facility does not handle resident's money.

Continued on LIC 809-C

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

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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Document Has Been Signed on 08/20/2024 02:49 PM - It Cannot Be Edited

Created By: Jose Villalobos On 08/20/2024 at 02:11 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: 08/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87463(c)

Reappraisals

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in (3) of (3) resident files reviewed had appraisails over a year old which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/03/2024
	Plan of Correction
1 2 3 4	Facility to update resident appraisals and provide LPA copies by POC due date.

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:

Fernando Fierros

LICENSING EVALUATOR NAME:

Jose Villalobos

LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ALONDRA GUEST HOME	FACILITY NUMBER: 198602557
	VISIT DATE: 08/20/2024

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Incident Medical and Dental: LPA reviewed medications for three (3) Residents. 30-day supply of resident medications were observed. The medications are centrally stored in locked cabinet. Centrally Stored Records for medications are kept. Medication stored matches the medication record for each resident.

Staffing: Sufficient caregiver staff provide care and supervision to the residents.

Personnel Records/Staff Training: Administrator certificate is current. Personnel files were reviewed. LPA reviewed a total of three (3) Staff files. LPA observed required documents for each. Proof of staff training was reviewed. 1st Aid/CPR records are current.

Resident Records/Incident Reports: A total of three (3) resident files were reviewed containing admission agreements, Physician's Reports, Appraisals, TB clearance, Functional Capability Assessment, and emergency information forms were observed. Appraisals on file are over a year old for each resident.

Residents Right-Information: RCFE complaint poster and Personal rights were observed and its posted near the entrance.

Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Indoor and outdoor activities are performed. The facility does not have a Resident Council.

Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies.

Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place and was posted today.
There is currently no Dementia resident residing in the facility.

Residents with Special Health Needs: No residents receive home health services. Postural support observed. (1) resident with half bed rails. No residents are on hospice. No residents have prohibited health conditions. No residents have restricted health conditions.

Per title 22 regulations, a deficiency is being cited on todays visit. Please see attached 809-D page. Exit Interview conducted. Appeal rights discussed. A copy of this report and the appeal rights were provided.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

LIC809 (FAS) - (06/04)

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