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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603126
Report Date: 06/07/2022
Date Signed: 06/07/2022 01:32:52 PM

Document Has Been Signed on 06/07/2022 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:ANL FACILITY HOME INCFACILITY NUMBER:
198603126
ADMINISTRATOR:BULOSAN, LUZVIMINDA AFACILITY TYPE:
740
ADDRESS:12073 HIGHDALE STTELEPHONE:
(562) 310-4871
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 6CENSUS: 3DATE:
06/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:21 AM
MET WITH:Luzviminda Bulosan, AdministratorTIME COMPLETED:
01:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Administrator Luzviminda Bulosan and explained the purpose of the visit. There are 3 residents ages 60 and above. The facility has a Dementia waiver, and a hospice waiver for 2 residents. Facility is a single story home located in a residential area consisting of 4 bedrooms (2 shared & 2 private), living room/dining area, kitchen, outdoor covered patio area, shed, and laundry area located in the backyard porch area. There is a detached garage in the rear of the property presently being used as storage and staff "resting area". The last emergency disaster drill was conducted on 5/17/2022. Administrator certificate expires 9/25/2022.

The following was inspected and observed during the inspection:
  • The interior and exterior physical plant was inspected.
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical
  • distancing. Facility has an approved COVID-19 mitigation plan. LPA was screened upon entry by staff.
  • Room # 4 is designated as the COVID-19 isolation room if needed.
  • Three (3) centrally stored resident medication records were reviewed.
  • Due to cognitive impairment residents in care do not wear masks.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days was observed.
  • A posted Emergency Disaster Plan was observed.
  • Sufficient supply of Personal Protective Equipment (PPEs) was observed.
  • Both exterior side gates had locks on the exit doors. The locks were immediately removed.
  • A couch, foldable beds, bed, and staff personal belongings were observed. Administrator stated it is "sometimes" used by Administrator/Licensee & spouse to rest between shifts. The plan of operation staffing plan and facility sketch does not indicate the garage is to be used as a staff room. "Between 10 pm and 6 am, at least one staff person shall be awake and on duty if any resident with Dementia .... require night supervision."
Deficiencies were cited. See LIC 809D.
Exit interview was conducted with Luzviminda Bulosan . A copy of the report and appeal rights were issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2022
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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Document Has Been Signed on 06/07/2022 01:32 PM - It Cannot Be Edited


Created By: Noemi Galarza On 06/07/2022 at 12:57 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: ANL FACILITY HOME INC
FACILITY NUMBER: 198603126

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(I)(2)
87705(l)(2). 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:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that both exterior side yard gates had a lock on the metal doors, which is a fire code violation and poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/07/2022
Plan of Correction
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Locks shall be removed from all exit doors. Staff immediately removed the lock and ensured the door knob mechanism is able to be opened from the inside of the gate. ****Cleared during the visit.
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:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/07/2022 01:32 PM - It Cannot Be Edited


Created By: Noemi Galarza On 06/07/2022 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: ANL FACILITY HOME INC
FACILITY NUMBER: 198603126

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)
87307(a). Personal Accommodations and Services. Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility.

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 in that LPA observed foldable beds, couch, bed, and staff personal belongings in half of the garage indicating that staff sleep there; which poses/posed a potential health, safety or personal rights risk to persons in care. Pictures were taken.
POC Due Date: 06/21/2022
Plan of Correction
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Licensee shall submit a written plan of correction along with picture proof of corrections by POC due date. NOTE: The plan of operation and facility sketch do not state the garage will be used as a staff room.
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:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2022


LIC809 (FAS) - (06/04)
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