<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603358
Report Date: 11/19/2024
Date Signed: 11/19/2024 10:27:55 AM

Document Has Been Signed on 11/19/2024 10:27 AM - 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 HOMEFACILITY NUMBER:
198603358
ADMINISTRATOR/
DIRECTOR:		JABONERO, JANICE RACHELLEFACILITY TYPE:
740
ADDRESS:13449 BIOLA AVETELEPHONE:
(714) 244-5885
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY: 6CENSUS: 6DATE:
11/19/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:47 AM
MET WITH:Nino Lasman - CaregiverTIME VISIT/
INSPECTION COMPLETED:
10:41 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Erik Zaragoza conducted a subsequent unannounced Required 1-year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools to complete the annual inspection that had begun on 11/15/2024. LPA met with Janice Jabonero, administrator for the facility, and explained the purpose of the visit. 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.

Items Covered in the initial visit on 11/15/2024:

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.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
Document Has Been Signed on 11/19/2024 10:27 AM - It Cannot Be Edited


Created By: Erik Zaragoza On 11/19/2024 at 10:04 AM
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: 11/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(a)(1)
Hospice Care for Terminally Ill Residents
(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (1) The licensee has received a hospice care waiver from the department.

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, because the facility has an approved hospice waiver for 4 residents however there are 5 on hospice which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/26/2024
Plan of Correction
1
2
3
4
**POC Cleared During Visit because administrator has emailed LPA the hospice waiver increase request** Administrator is to ensure that an approved hospice waiver to cover all residents is on file at all times. Administrator is to submit to LPA a hospice waiver increase request to 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: 11/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
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: 11/19/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
·Water temperature readings for one of the bathrooms in the home fell within the required range of 105 - 120 degrees Fahrenheit.

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.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: 11/19/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Items covered during today's visit on 11/19/2024:

Staffing:

· Eight (8) full-time staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

· Five (5) staff files were reviewed for criminal background clearance and training.


· All staff records reviewed have health a health screening with a Tuberculosis clearance, and all staff have First Aid/CPR trainings that are active.
· The administrator’s certificate expires on 3/26/2026.

Incident Medical and Dental:

· All residents have an Appraisal/Needs and Services Plan on file.

· Staff training was on file.

Disaster Preparedness:

· Emergency and Disaster Plan was publicly posted within the facility.

· The last emergency and disaster drill was conducted on 10/1/2024.

Planned Activities:

· Sufficient Space is provided to accommodate both indoor and outdoor activities.

· Sufficient equipment and supplies are provided to meet the requirements of the activity program.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: 11/19/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Residents with Special Health Care Needs:

· There are five (5) residents who are currently receiving hospice services, however the facility license currently has an approved hospice waiver for four (4) residents. Administrator emailed LPA the hospice increase request for six (6) residents and the POC will be cleared during the visit.

· There is an adequate number of staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her appraisal.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during the visit is documented on the LIC809D page. 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: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5