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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602639
Report Date: 08/14/2023
Date Signed: 08/14/2023 03:24:56 PM

Document Has Been Signed on 08/14/2023 03:24 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
GREATER LA AC/SC, 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:
08/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:51 AM
MET WITH:Conchita Passion, DSP TIME COMPLETED:
03:39 PM
NARRATIVE
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LPA Alberto Lopez made unannounced visit to conduct the annual inspection. LPA met with Conchita Pasion and Bob Allado Live in caregivers and explained the purpose of 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.


LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents and medications. Disposals of trash are done immediately after changing a resident. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies but did not have an infection Control Plan at facility.
Operational Requirements: The facility has a dementia care plan to accept or retain residents with dementia. There are currently 2 non-ambulatory 1 ambulatory and 3 bedridden residents residing at the facility. The facility has the sufficient amount of liability insurance covering injury to residents and guest.
Physical Plant & Environment Safety: There are no pool or bodies of water at the premises. There are 6 resident rooms bedrooms and two staff bedroom, 4 bathrooms, living room, dining room, and kitchen, Facility has operable smoke and carbon monoxide detectors located in each room and hallway. Knives, cleaning solutions, and disinfectants are locked in the cabinets. No firearms or weapons are stored at the facility. LPA measured the hot water temperature in the bathrooms and kitchen sink. The hot water temperature in the bathrooms were measured between 108.1 - 113.7 degrees F which is within required range of 105-120 degrees F.

Continued on (809C)
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 08/14/2023 03:24 PM - It Cannot Be Edited


Created By: Alberto Lopez On 08/14/2023 at 02:25 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: 08/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87606(c)
Care of Bedridden Residents
(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and interview the licensee did not comply with the section cited above. Facility has 3 bedridden residents and only permitted one which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2023
Plan of Correction
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Facility will contact Fire department to get Fire Clearance for 2 additional residents and send proof to LPA by POC date.
Type A
Section Cited
HSC
1569.72(c)
Levels of Care
(c) Notwithstanding paragraph (2) of subdivision (a), bedridden persons may be admitted to, and remain in, residential care facilities for the elderly that secure and maintain an appropriate fire clearance. A fire clearance shall be issued to a facility in which one or more bedridden persons reside if either of the following conditions are met:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and interview the licensee did not comply with the section cited above. Facility has 3 bedridden residents and only permitted one which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2023
Plan of Correction
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Facility will contact Fire department to get Fire Clearance for 2 additional residents and send proof to LPA by POC date.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2023


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Page: 2 of 7
Document Has Been Signed on 08/14/2023 03:24 PM - It Cannot Be Edited


Created By: Alberto Lopez On 08/14/2023 at 02:25 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: 08/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(a)(12)
Plan of Operation
(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: (12) The Infection Control Plan pursuant to Section 87470.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Facility did not have plan of operation at facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2023
Plan of Correction
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Administrator will provide Plan of Operation to LPA by POC date.
Type B
Section Cited
CCR
87303(e)(6)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Shower faucet is leaking which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2023
Plan of Correction
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Administrator will repair or replace shower facet and send proof to LPA by POC date.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2023


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 08/14/2023 03:24 PM - It Cannot Be Edited


Created By: Alberto Lopez On 08/14/2023 at 02:25 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: 08/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Resident files are missing updated Admission Agreements which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2023
Plan of Correction
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Administrator will send Admission Agreements for all residents and update then when changes in the agreement have changed and send proof to LPA by POC date.
Type B
Section Cited
CCR
87458(b)(5)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (5) The determination whether the person is ambulatory or nonambulatory as defined in Section 87101(a) or (n), or bedridden as defined in Section 87455(d). The assessment shall indicate whether nonambulatory status is based upon the resident's physical condition, mental condition or both.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Facility has failed to update residents records that define the resident as ambulatory or non ambulatory or bedridden which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2023
Plan of Correction
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Administrator will obtain updated status of ambulatory or non ambulatory or bedridden status on all residents that are missing the updated status (R3,R4,R5) and send proof to LPA by POC date.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2023


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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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: D & L RESIDENTIAL CARE HOME 2
FACILITY NUMBER: 198602639
VISIT DATE: 08/14/2023
NARRATIVE
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Staffing: There appears to be sufficient staffing at the facility. The administrator's (Rafeal Diaz) certificate has expired. Staff employed are all over the age of 18.
Personnel Records-Training: Staff files are maintained at the facility. Staff have current CPR/first aid training and sufficient on-going training.
Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Identification & Emergency Information, Original Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. All residents files need updated Admission Agreements and Physicians reports.
Resident Rights-Information: The Complaint poster and Residents personal rights are posted by the main entry. Visiting hours are posted.
Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability.
Food Service: There are sufficient food supplies of 2-day perishable. Seven-day non-perishable items are not sufficient. The food is properly stored in the refrigerator to avoid cross contamination.
Incidental Medical & Dental: The medications are centrally stored and in their original containers. During the visit today, LPA reviewed all 6 residents' medication, and all medication is administered according to doctor’s orders.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites.
Residents with Special Health Needs: The facility accepts and retains residents with dementia and/or hospice. The staff received training on appropriately caring for residents with dementia, those on hospice, and receiving oxygen. No Smoking - Oxygen signs are not posted on the doors of residents using oxygen.

Deficiencies as well as technique advisories were given

Exit interview conducted and copy of report and appeal rights provided.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023
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