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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602974
Report Date: 12/09/2021
Date Signed: 12/09/2021 05:11:39 PM

Document Has Been Signed on 12/09/2021 05:11 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:CERRITOS RESIDENCE CAREFACILITY NUMBER:
198602974
ADMINISTRATOR:NORA, PETERFACILITY TYPE:
740
ADDRESS:20111 GRIDLEY RDTELEPHONE:
(562) 809-3453
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 6CENSUS: 6DATE:
12/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Peter Nora TIME COMPLETED:
02:00 PM
NARRATIVE
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LPA Angelica Rea conducted an unannounced visit for the purpose of conducting the required annual inspection. On today's visit LPA met with Administrator, Peter Nora who assisted with the visit.

LPA Rea discussed infection control practices with Mr. Nora, toured the facility inside and out, reviewed food supply, reviewed staff files, and reviewed resident medications.

Bedrooms have the required furniture including bedframes, dressers, lamps and chairs. Beds have the required linen and the linen is in good condition. Passageways and exits are free of obstruction. The front and backyard are well maintained. The resident bathroom is clean and have the required grab bars in the shower and near the toilet for non-ambulatory residents. Showers also have non-skid materials. The hot water temperature measured at 117.5 degrees F. The facility temperature at the time the visit was comfortable. There is sufficient lighting throughout the facility. There are smoke detectors located throughout the facility, tested and operational. There is a carbon monoxide detector located in the hallway, tested and operational.
LPA observed a sufficient supply of PPE in the garage. Infection control signs were observed throughout the facility.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies cited on 809-D. Exit interview held and a copy of the report was provided to Mr. Nora.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2021
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 12/09/2021 05:11 PM - It Cannot Be Edited


Created By: Angelica Rea On 12/09/2021 at 01:05 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: CERRITOS RESIDENCE CARE
FACILITY NUMBER: 198602974

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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87465(a)(5) Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed. This requirement is not being met as evidenced by: LPA Rea observed that resident #1 did not receive Senna 8.6 mg tablet from 11/18/21 - 12/9/21.
POC Due Date: 12/16/2021
Plan of Correction
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Administrator will ensure that residents are assisted with self-administered medications as needed. Administrator will provide proof of staff medication training to LPA 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:Lisa Hicks
LICENSING EVALUATOR NAME:Angelica Rea
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2021


LIC809 (FAS) - (06/04)
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