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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602639
Report Date: 07/22/2022
Date Signed: 07/22/2022 12:38:08 PM

Document Has Been Signed on 07/22/2022 12:38 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:RAFAEL DIAZFACILITY TYPE:
740
ADDRESS:1036 S. BARRANCA AVENUETELEPHONE:
(562) 774-7167
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY: 6CENSUS: 6DATE:
07/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Rafael Diaz, administratorTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Rafael Diaz, administrator, who assisted with the visit. The facility has a capacity of six (6) residents. It is licensed to serve elderly residents age 60 and above, approved for six (6) non-ambulatory, of which one (1) may be bedridden. Facility approved for two (2) hospice waivers. The facility cares for elderly residents with dementia. Currently, facility has three residents with dementia. Annual fees are current.

During the visit, the infection control domain tool was used, a tour of the facility was conducted, food supply was reviewed, and medications were reviewed.

The facility is located in a residential neighborhood, a single-story home and consisted of three (3) resident’s bedrooms, three (3) bathrooms, living room, kitchen, and dining room. Administrator certificate is current and the expiration date is 10/17/2023. Last fire drill was conducted on 04/19/22.

A physical tour was conducted. Residents’ rooms were well furnished and in compliance. Bathrooms inspected were clean, operable, with the required grab bars and non-skid materials in the shower. Hot water temperature was measured at 117.5 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies were observed. No pools and bodies of water on the premises. No firearms on the premises. Facility maintained a comfortable temperature for residents. Auditory alarm devices to monitor exits were operable. Interior and exterior space available to permit residents to wander freely and safely.

(- continued in LIC 809C-)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2022
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
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: 07/22/2022
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Sufficient supply of perishable and nonperishable foods is observed. Knives, tools, sharp items are inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable. Fire extinguishers are fully charged.

Mandated documents and signages are posted in common areas. The outdoor activity area has a shaded patio with ample seating. Medication are centrally stored in a locked cabinet in the kitchen and inaccessible to residents. Resident records are stored in a locked cabinet and inaccessible to residents. Toxic substances are inaccessible to residents. Outdoor facility space used for residents and leisure are completely enclosed by a fence with self-closing gates.

Deficiencies were observed and cited per California Code of Regulations, Title 22 in LIC 809 D.

An exit interview was conducted. This report is discussed and provided to facility Licensee /Administrator, whose signature on this form confirm receipt of these documents. A copy of appeal rights was provided.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/22/2022 12:38 PM - It Cannot Be Edited


Created By: Bonnie Tao On 07/22/2022 at 12:04 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: 07/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(5)
Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
LPA observed R1 has medications which were pre-poured for 7 days in a morning/afternoon/evening in a 7-day pill container. The 7-day pill container and original bubble packs were locked and unable to be accessed.
Deficient Practice Statement
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Based on observation and medication review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2022
Plan of Correction
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Licensee agrees to ensure that medication stays in its originally received container. Licensee will provide in-service trainings to staff on handling medication. Administrator agrees to review regulation 87465 and send a letter stating Licensee understand and will in compliance with regulation to CCL by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Fernando Fierros
LICENSING EVALUATOR NAME:Bonnie Tao
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2022


LIC809 (FAS) - (06/04)
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