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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602638
Report Date: 07/23/2021
Date Signed: 07/23/2021 01:15:35 PM

Document Has Been Signed on 07/23/2021 01:15 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:D & L RESIDENTIAL CARE HOME 1FACILITY NUMBER:
198602638
ADMINISTRATOR:DIAZ, RAMONFACILITY TYPE:
740
ADDRESS:330 WEST CITRUS EDGE STREETTELEPHONE:
(562) 774-7167
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY: 6CENSUS: 4DATE:
07/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Caregivers/ Cordero Nelson and Tongol AliciaTIME COMPLETED:
01:30 PM
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Licensing Program Analysts (LPAs) Nune Margaryan and Tony Vasallo conducted an unannounced Required One (1) year - Inspection to this facility. Upon arrival, LPAs met with Caregivers Cordero Nelson and Tongol Alicia who assisted with the visit. The purpose of the visit was explained. Administrator Rafael Diaz also called and notified for the visit. The facility is licensed to serve 6 (six) non-ambulatory residents ages 60 and over of which 1 (one) may be bedridden and facility is approved to retain 2 residents on hospice. The facility cares for elderly residents with dementia. Currently 2 residents on hospice .
LPAs Nune Margaryan and Tony Vasallo inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms, resident bathrooms, laundry room, living room, and outside areas of the facility to ensure compliance with Title 22 regulations. LPAs also conducted the infection control domain tool.

A physical plant tour was conducted at 9:32 am. A tour of the single-story facility includes: 2 private rooms and 2 share rooms for a total 4 bedrooms. There is 1 staff room, 2 bathrooms, a living room, kitchen, dining area, and indoor/outdoor activity area. The bathrooms are clean and operational w/grab bars and non-skid surface/mats in place. However hot water temperature was 132.8 degree F which is beyond the required range of 105 degree F to 120 degree F not in compliance with the California Code of Regulations Title 22.

The facility doesn't have a central A/C, however each bedroom is equipped with portable fans and or wall A/C units. The common areas (dining room, living room) appeared to be clean and were properly furnished. Resident rooms were sanitary and had the required furniture and furnishings. The kitchen was observed for the ability to prepare and serve food. LPAs observed a sufficient supply of perishables/non-perishables and emergency food supply. All mandated documents are posted in a prominent place. The facility’s smoke detectors are battery operated and were tested and observed to be operational. The fire extinguisher is fully charged and meets Title 22 Regulations.

Cont. on 809C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: D & L RESIDENTIAL CARE HOME 1
FACILITY NUMBER: 198602638
VISIT DATE: 07/23/2021
NARRATIVE
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The first-aid kit was observed.
There is no pool or other large bodies of water. The facility is required to have auditory devices on all exit doors due to caring for residents with dementia..

The following concerns were observed during today's visit;


LPAs observed the auditory chimes on the front door and back door are missing, which is required with dementia residents.
LPAs observed chemicals under the sink in the kitchen area left unlocked and accessible to the residents.
LPAs observed a latch on the outside the door in bedroom #2.
LPAs observed Resident #1 (R1) has prescribed daily eye drops (Brinzolamide Ophthalmic Suspension 1% and Combigan 0.2%-0.5% solution. LPAs observed bottles were sealed therefore R1 is not receiving the daily medication.
LPAs observed that Residents #1; #2 ;#3 (R1; R2; R3) and Staff #1 (S1) did not have complete record at the facility.

The following deficiencies were observed to be in violation of California code of Regulations, Title 22, Division 6 (refer to 809D)
An exit interview was conducted, and a copy of this report was provided to the Staff along with the Appeals Rights.




SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 07/23/2021 01:15 PM - It Cannot Be Edited


Created By: Nune Margaryan On 07/23/2021 at 12:23 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: D & L RESIDENTIAL CARE HOME 1
FACILITY NUMBER: 198602638

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2021

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
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Based on observation water temperature was 132.8 degree which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2021
Plan of Correction
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Administrator will send to LPA log sheet with the adjusted water temperature.
Type A
Section Cited
CCR
87465(a)(5)
Incidental Medical and Dental Care Services
(5) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation and record reviews Resident #1 (R1) has prescribed daily eye drops (Brinzolamide Ophthalmic Suspension 1% and Combigan 0.2%-0.5% solution. LPAs observed bottles were sealed therefore R1 is not receiving the daily medication which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2021
Plan of Correction
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Administrator shall ensure to send LPA MAR for the Resident ensuring medication is provided daily.
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:Wei Siew Ho
LICENSING EVALUATOR NAME:Nune Margaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2021


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 07/23/2021 01:15 PM - It Cannot Be Edited


Created By: Nune Margaryan On 07/23/2021 at 12:23 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: D & L RESIDENTIAL CARE HOME 1
FACILITY NUMBER: 198602638

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation LPAs observed chemicals and cleaning supplies under the sink in the kitchen area left unlocked and accessible to the residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2021
Plan of Correction
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Staff removed the items during the visit.
Type A
Section Cited
CCR
87705(j)
Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation LPAs observed the auditory chimes on the front door and back door are missing which is required with dementia residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2021
Plan of Correction
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Administrator will install required equipment and will send the pictures to LPA.
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:Wei Siew Ho
LICENSING EVALUATOR NAME:Nune Margaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2021


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 07/23/2021 01:15 PM - It Cannot Be Edited


Created By: Nune Margaryan On 07/23/2021 at 12:23 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: D & L RESIDENTIAL CARE HOME 1
FACILITY NUMBER: 198602638

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2021

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 observation LPAs observed that Residents #1; #2 ;#3 (R1; R2; R3) did not have complete record at the facility. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/06/2021
Plan of Correction
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Administrator will ensure that Residents file will be complete and will send (by fax or mail) to LPA.
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation LPAs observed that Staff #1 did not have complete record at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/06/2021
Plan of Correction
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Administrator will ensure that Residents file will be complete and will send (by fax or mail) to LPA.
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:Wei Siew Ho
LICENSING EVALUATOR NAME:Nune Margaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2021


LIC809 (FAS) - (06/04)
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