198603358-11-15-2024-28-AS-EZAA-DB2W2H-20241115155423

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603358
Report Date: 11/15/2024
Date Signed: 11/15/2024 03:55:05 PM

Document Has Been Signed on 11/15/2024 03:55 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:	SUPERCARE GUEST HOME		FACILITY NUMBER:	198603358
ADMINISTRATOR/ DIRECTOR:	JABONERO, JANICE RACHELLE		FACILITY TYPE:	740
ADDRESS:	13449 BIOLA AVE		TELEPHONE:	(714) 244-5885
CITY:	LA MIRADA	STATE: CA	ZIP CODE:	90638
CAPACITY: 6		CENSUS: 6	DATE:	11/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:37 PM
MET WITH:	Nino Lasman - Caregiver		TIME VISIT/ INSPECTION COMPLETED:	04:09 PM

NARRATIVE

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Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1-year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Pamela Joaquin, Caregiver for the facility, and explained the purpose of the visit. Licensee Ruby Cruz arrived shortly thereafter. There are six (6) residents residing within the home.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs.

Infection Control:

· Infection control practices were observed.

· Infection control plan is on file.

Physical Plant/Environment Safety:

· The facility is a single-story home located in a residential neighborhood. It is licensed for a capacity of six (6) residents, six (6) of which may be non-ambulatory, one (1) of which may be bedridden, and a hospice waiver approved for four (4) residents. The facility consists of a kitchen, a dining room, living room, one (1) staff bedroom, three (3) resident bedrooms, one (1) resident bathroom of which had a hot water temperature of 109.5 Degrees Fahrenheit, along with a backyard that contains a shaded area and an attached garage which contains extra toiletries, and food supplies The facility was observed to be in good repair.

· The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. The facility has one (1) fully charged fire extinguisher in the facility.
· Water temperature readings for one of the bathrooms in the home fell within the required range of 105 - 120 degrees Fahrenheit.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SUPERCARE GUEST HOME	FACILITY NUMBER: 198603358
	VISIT DATE: 11/15/2024

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Operational Requirements:

· The Program Design was reviewed.

· Fire clearance was approved by LA County Fire Department for a capacity of six (6) residents, six (6) of which may be non-ambulatory, one (1) of which may be bedridden, and a hospice waiver approved for four (4) residents.

· Care and supervision to meet the clients’ needs was observed.

Staffing:

· Five (5) full-time staff members provide care and supervision to the clients.

Resident Rights/Information:

· Physician orders were reviewed for six (6) resident files.

· Medications were also reviewed for six (6) residents.

Resident Records/Incident Reports:

· Six (6) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, and medication records were reviewed.

· An appraisal for one (1) out of six (6) residents has not been completed within the past year.

Food Service:

· The kitchen was inspected and did not have a sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit is documented on the LIC809D pages. Exit interview held and a copy of the report along with appeal rights were provided.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 11/15/2024 03:55 PM - It Cannot Be Edited

Created By: Erik Zaragoza On 11/15/2024 at 03:38 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: SUPERCARE GUEST HOME	FACILITY NUMBER: 198603358
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87463(c)

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 6 residents, as one resident's appraisal had not been completed within the past 12 months, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/29/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator is to ensure that residents have a reappraisal conducted at least once every 12 months at all times. Licensee/Administrator is to conduct a reappraisal for the identified resident and send proof to LPA that it has been conducted by the POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

David Sicairos

LICENSING EVALUATOR NAME:

Erik Zaragoza

LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 11/15/2024 03:55 PM - It Cannot Be Edited

Created By: Erik Zaragoza On 11/15/2024 at 03:44 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: SUPERCARE GUEST HOME	FACILITY NUMBER: 198603358
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(b)(26)

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premesis. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in six out of six resident, because the facility did not meet the sufficient 2-day perishable and 7-day nonperishable food supply for 6 residents, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/16/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator is to ensure that the facility has the required ammount of food in the facility at all times. Licensee/Administrator is to purchase the required supply of perishable and non-perishable foods and email the receipt of the purchase to the LPA by the POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

David Sicairos

LICENSING EVALUATOR NAME:

Erik Zaragoza

LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC809 (FAS) - (06/04)

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