<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602639
Report Date: 07/08/2021
Date Signed: 02/06/2023 01:32:48 PM

Document Has Been Signed on 02/06/2023 01:32 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 2FACILITY NUMBER:
198602639
ADMINISTRATOR:DIAZ, RAMONFACILITY TYPE:
740
ADDRESS:1036 S. BARRANCA AVENUETELEPHONE:
5627747167
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY: 6CENSUS: 6DATE:
07/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
07:00 AM
MET WITH:Caregivers: Pasion Conchita & Reyes FeTIME COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
This page is amended to add additional information and to correct a regulation code on a deficiency cited.

Licensing Program Analysts (LPAs) Nune Margaryan and Joe Katrdzhyan conducted an unannounced Required One (1) year - Inspection to this facility. Upon arrival, LPAs met with Caregivers / Reyes Fe and Pasion Conchita who assisted with the visit. The purpose of the visit was explained. 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.
LPAs Nune Margaryan and Joe Katrdzhyan 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 8:45 am. A tour of the single-story facility includes: 6 individual bedrooms for residents, 1 staff room, 3 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. The hot water temperature was tested throughout the facility and maintained within the required range of 105-120*F. 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 (located in the kitchen) is fully charged and meets Title 22 Regulations.

The first-aid kit (located in the secured medicine cabinet) 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.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 07/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
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 2
FACILITY NUMBER: 198602639
VISIT DATE: 07/08/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The following concerns were observed during today's visit;
  • At 10:15AM, LPAs observed the exterior door located on the gate near the patio area was being locked by using a privacy lock from the inside preventing residents from exiting the facility in case of an emergency.
  • At 10:15AM, LPAs observed the self closing mechanism/latch on the exit gate near the patio area was in disrepair as the gate would not self-close.
  • During today’s visit, LPAs observed the auditory chimes on the sliding doors in bedrooms 1, 2 and 4 were missing. The auditory chime in bedroom #7 was inoperable.
  • At 10:35AM, LPAs observed bleach, pine sol, bathroom cleaner, Xtra detergent, WD40, and glass cleaner in the laundry area left unlocked and accessible to the residents.
  • At 10:45AM, LPAs found a sharp knife underneath the kitchen cabinet left accessible to residents.
  • During today’s visit, LPAs observed full bed rails in bedrooms 4, 5 and 7. Per staff, Residents in bedrooms 4, 5 and 7 are not enrolled in hospice and are not receiving hospice services.
  • At 10:50AM, LPAs observed Docusate Sodium 100 MG Capsule (Take one capsule by mouth twice daily) was not administered to R4 on 7/7/21, evening dose.
  • During today’s visit, LPAs observed facility to have 3 residents on hospice (R1 – R3), but the facility has an approved hospice waiver on file for 2 residents.

There are deficiencies observed during today's visit and are cited under the California Code of Regulations Title 22 on the LIC 809D.
Exit interview was conducted. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 02/06/2023 01:33 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 07/12/2021 01:45 PM


Created By: Nune Margaryan On 07/08/2021 at 12:34 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: D & L RESIDENTIAL CARE HOME 2
FACILITY NUMBER: 198602639

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/19/2021
Section Cited

1
2
3
4
5
6
7
Care of Persons with Dementia. The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates. This requirement is not met as evidenced by:
8
9
10
11
12
13
14
At 10:15AM, LPAs observed the exterior door located on the gate near the patio area was being locked by using a privacy lock from the inside preventing residents from exiting the facility in case of an emergency. This poses an immediate health and safety concern for the residents in care.
8
9
10
11
12
13
14
Type A
07/09/2021
Section Cited

1
2
3
4
5
6
7
Care of Persons with Dementia. Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents.
This requirement is not met as evidenced by:
8
9
10
11
12
13
14
At 10:15AM, LPAs observed the self closing mechanism/latch on the exit gate near the patio area was in disrepair as the gate would not self-close. This poses an immediate health and safety concern for the residents in care.
8
9
10
11
12
13
14
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: 07/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2021


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 07/08/2021 03:21 PM - It Cannot Be Edited


Created By: Nune Margaryan On 07/08/2021 at 12:46 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 2
FACILITY NUMBER: 198602639

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/09/2021
Section Cited

1
2
3
4
5
6
7
Care of Persons with Dementia. 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;

8
9
10
11
12
13
14
During today’s visit, LPAs observed the auditory chimes on the sliding doors in bedrooms 1, 2 and 4 were missing. The auditory chime in bedroom #7 was inoperable.
This poses health and safety risk for the residents in care.

8
9
10
11
12
13
14
Type A
07/08/2021
Section Cited

1
2
3
4
5
6
7
Care of Persons with Dementia. The following shall be stored inaccessible to residents with dementia:Knives,matches, firearms, tools and other items that could constitute a danger to the resident(s).This requirement is not met as evidenced by;
s.
8
9
10
11
12
13
14
At 10:45AM, LPAs found a sharp knife underneath the kitchen cabinet left accessible to residents. This poses health and safety risk for the residents in care
8
9
10
11
12
13
14
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: 07/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2021


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 07/08/2021 03:21 PM - It Cannot Be Edited


Created By: Nune Margaryan On 07/08/2021 at 12:55 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 2
FACILITY NUMBER: 198602639

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/08/2021
Section Cited

1
2
3
4
5
6
7
Care of Persons with Dementia. The following shall be stored inaccessible to residents with dementia: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;
8
9
10
11
12
13
14
At 10:35AM, LPAs observed bleach, pine sol, bathroom cleaner, Xtra detergent, WD40, and glass cleaner in the laundry area left unlocked and accessible to the residents. This poses health and safety risk for the residents in care.
8
9
10
11
12
13
14
Type A
07/09/2021
Section Cited

1
2
3
4
5
6
7
Postural Supports. Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. 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;
8
9
10
11
12
13
14
During today’s visit, LPAs observed full bed rails in bedrooms 4, 5 and 7. Per staff, Residents in bedrooms 4, 5 and 7 are not enrolled in hospice and are not receiving hospice services. This poses an immediate health and safety risk to the residents in care.
8
9
10
11
12
13
14
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: 07/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2021


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 07/08/2021 03:21 PM - It Cannot Be Edited


Created By: Nune Margaryan On 07/08/2021 at 01:25 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 2
FACILITY NUMBER: 198602639

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/09/2021
Section Cited

1
2
3
4
5
6
7
Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications as needed.
This requirement is not met as evidenced by;
At 10:50AM, LPAs observed Docusate Sodium 100 MG Capsule (Take one capsule by mouth twice daily) was not administered to R4 on 7/7/21, evening dose.
Type B
07/22/2021
Section Cited

1
2
3
4
5
6
7
Hospice Waiver. In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department. To obtain this waiver the licensee shall submit a written request for a waiver to the Department on behalf of any residents who may request retention, and any future residents who may request acceptance, along with the provision of hospice services in the facility.This requirement is not met as evidenced by:
8
9
10
11
12
13
14
During today’s visit, LPAs observed facility to have 3 residents on hospice (R1 – R3), but the facility has an approved hospice waiver on file for 2 residents.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
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: 07/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2021


LIC809 (FAS) - (06/04)
Page: 6 of 6