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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603193
Report Date: 11/30/2021
Date Signed: 11/30/2021 03:16:03 PM

Document Has Been Signed on 11/30/2021 03:16 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 ASSISTED LIVINGFACILITY NUMBER:
198603193
ADMINISTRATOR:SANTA ANA, OSVALDOFACILITY TYPE:
740
ADDRESS:18511 KAMSTRA AVENUETELEPHONE:
(562) 637-3392
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 6CENSUS: 4DATE:
11/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Runette Catibog - AdministratorTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPA met with Administrator and explained the reason for the visit. The physical plant was toured, resident files and medications records were reviewed, staff files were reviewed and food supply was inspected. Facility is licensed for a capacity of 6 in the age range of 60 and over, in which 6 can be non-ambulatory and 1 may be bedridden, and approved for 2 hospice waivers.

LPA and Administrator Runette Catibog toured the facility which included the following: living room, kitchen, dining area, 2 bathrooms, 3 resident rooms, 1 staff room, backyard, and attached garage.

Passageways and exits are free of obstruction. The water temperature was tested in the 2 resident bathrooms and measured between 106.5 - 118.6 degrees F which is within the required 105 - 120 degrees F. The resident bathrooms are clean and have the required grab bars in the shower and near the toilet for non-ambulatory residents. Showers also have non-skid materials. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have sufficient closet space. There is a cabinet in the hallway with extra clean linen. Resident beds have the required linen and the linen is in good condition. Smoke detectors were observed throughout the facility and in each resident room. Carbon monoxide detector was observed in the dining area. Auditory devices were seen on exit doors which are required for dementia residents and were operating a the time of visit. LPA observed 1 fire extinguisher in the kitchen which was fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked under the kitchen sink and are inaccessible to residents. Cleaning supplies and toxins are locked under the kitchen sink and are inaccessible to residents. The First Aid kit located in a closet in the living room was inspected and was fully stocked with current manual. Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing. Sufficient supply of 2 days perishable & 7 days non-perishable foods were observed in the kitchen and garage.
(CONTINUED TO LIC809C)
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2021
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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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: CERRITOS ASSISTED LIVING
FACILITY NUMBER: 198603193
VISIT DATE: 11/30/2021
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Medications, resident files, and staff files are kept in a locked closet in the living room. The backyard is clean and there is a shaded seating area for the residents. No bodies of water were observed in the facility.

LPA reviewed 5 staff files and observed the following: 4 out of 5 staff have criminal record clearances and are associated to the facility, 5 out of 5 staff have proof of in-service training, 5 out of 5 staff files have health screenings with TB information, and 5 out of 5 staff have current first aid/CPR certificates. Staff #1 (S1) who was present at the facility does not have a criminal record clearance and facility did not have paperwork in the staff file to show that S1 has done a criminal background check.

LPA reviewed 4 residents' files and medication, and observed the following: 4 out of 4 resident have admission agreements on file, 4 out of 4 have their needs and services plans up to date, and 4 out of 4 have physician's reports on file and TB information, and 4 out of 4 have their medications documented properly and given as prescribed. According to the physician's reports the facility currently has 2 bedridden residents and the facility is only licensed for 1 bedridden.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there was two deficiency observed during the visit (refer to LIC809-D). Exit interview held and a copy of the report and appeal rights was provided.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/30/2021 03:16 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Luis Mora On 11/30/2021 at 01:34 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CERRITOS ASSISTED LIVING

FACILITY NUMBER: 198603193

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/30/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 5 staff. Staff #1 (S1) did not have a criminal background clearance, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2021
Plan of Correction
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Licensee shall complete a criminal background check for S1 by 12/01/2021 and submit proof of correction.
Under Appeal
Type A
Section Cited
CCR
87202(a)(2)
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. (2) Bedridden persons.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. The facility has 2 bedridden residents, but only licensed for 1 bedridden, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2021
Plan of Correction
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Licensee is to notify the Fire Department Fire Marshal and submit to a LIC 200 and facility sketch which clarifies the rooms with bedridden residents by 12/01/2021.
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:Rebecca Orendain
LICENSING EVALUATOR NAME:Luis Mora
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2021


LIC809 (FAS) - (06/04)
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