198603438-5-5-2021-28-AS-BTAO-C2QUD9-20210505152911

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603438
Report Date: 05/03/2021
Date Signed: 05/05/2021 03:30:12 PM

Document Has Been Signed on 05/05/2021 03:30 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:	NAGOMI HOME LLC		FACILITY NUMBER:	198603438
ADMINISTRATOR:	AYABE, TOKIE		FACILITY TYPE:	740
ADDRESS:	1128 N FAIRVALLEY AVE		TELEPHONE:	(626) 404-8798
CITY:	COVINA	STATE: CA	ZIP CODE:	91722
CAPACITY: 6		CENSUS: 0	DATE:	05/03/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Tokie Ayabe, administrator /applicant Naoko Koyama, nursing manager		TIME COMPLETED:	03:45 PM

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 Analysts (LPAs), Tao and Lopez conducted an announced pre-licensing inspection. This is a new application applying for Residential Care for Elderly. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s pre-licensing inspection was conducted telephonically with Applicants. LPAs met Tokie Ayabe, Licensee Applicant and staff, Koyama Naoko (LVN) at the virtual visit. The facility has a capacity of 6. The applicant is a Limited Liability Corp, Nagomi Home LLC. Fire clearance: Its fire clearance is approved for six (6) ambulatory, 0 non-ambulatory and 0 bedridden. The facility does not have a Dementia Care Program. This facility is granted a fire clearance on April 15, 2021 with a note stating, “Ambulatory Only.” No dementia residents admitted and delayed egress is not installed. Structure: The facility is a 2-story house. On the first floor, there are four (4) residents’ bedrooms, two (2) full residents’ bathrooms (with a shower area and a toilet), two (2) residents’ bathrooms with toilet only (no bathing area), a kitchen, a dining area near the kitchen, an activity room with a TV, an administrative room shared with nurse station and medication room, a common laundry room, a backyard, and detached garage. Passageways, walkways, stairs and patios are free from obstructions. The entrance and side areas are free of hazards and debris. On the second floor, there are four (4) staff bedrooms, a lounge area, one (1) staff bathroom with a bathtub (no toilet) and two (2) staff bathrooms with toilets only with no bath area. Second floor is for staff only and inaccessible to residents. Staff will live in Staff room A, B, and D. Applicant lives in Staff Room C. The facility is located in a residential neighborhood. (-continued LIC 809 C -)

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2021

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: NAGOMI HOME LLC	FACILITY NUMBER: 198603438
	VISIT DATE: 05/03/2021

NARRATIVE

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Signal system and Garage:
Facility does not have a signal system.
Detached garage is not accessible to residents.

Bedrooms for Residents:
Bedroom A, B, C and D have nightstand, adequate lighting, adequate closet and drawer space. Bedrooms are spacious and allow for easy passage between and comfortable for usage. Bedroom A, B, and C do not have a bed setting. Licensee Applicant stated the potential residents will bring their own bed. Bedroom D has a bed as a sample room and has an access to the backyard.

Bathrooms:
Toilet, wash basin, bathtub/shower in bathrooms are operable. Bedrooms for ambulatory residents are accommodated for residents. Grab bars are maintained for each toilet, bathtub and shower.
The bathrooms with bathing areas and toilets are located next to the kitchen and in Bedroom D on the first floor.

Food Service:
Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Dishwasher in kitchen properly installed and functioning.

Smoke Detectors:
Smoke detectors are combined with Carbon monoxide detectors. Total of thirteen (13) detectors are located in hallways and each room. They are operational and not hard wired.

Appliances:
Stove burners, oven, microwave, washer, and dryer working. There are two refrigerators, one is the kitchen and one additional refrigerator in the detached garage for food storage. Each refrigerator has a measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezer is at (0) zero degrees Fahrenheit. The residence is equipped with central air and heat.

(-Continued LIC 809 C -)

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2021

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: NAGOMI HOME LLC	FACILITY NUMBER: 198603438
	VISIT DATE: 05/03/2021

NARRATIVE

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Water Temperature:
Tested at 105. degrees Fahrenheit in kitchen sink.

Menu and phone:
Menus are available for review.
Free telephone is available for residents’ use and operable.

Fire extinguishers:
Two fire extinguishers are available in the facility. One is located on the first floor near kitchen mounted on wall and the other one is located at staff lounge room on the second floor. They are fully charged and last service was done in March 2021.

Clients & Staff Files:
Applicant will not handle cash resources for residents.

Reading Material, Games, Equipment & Materials:
The facility has recreational materials for the residents’ use, commensurate with the plan of operation. Due to COVID 19 pandemic, residents are encouraged to have activities in their own room.

Pool:
No bodies of water located at the facility.

Corrections needed:

Medications, First-Aid Kit & Book:
Medication cabinets or carts are not observed. They need to be installed with a lock and inaccessible to residents.
No first aid kit. The kit needs to have at least a thermometer, tweezers, scissors, antiseptic, bandages, and gauze.
No current copy of First Aid manual from American red cross First Aid kit manual. It needs to be available for staff use but inaccessible to residents.
(- Continued LIC 809 C -)

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2021

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: NAGOMI HOME LLC	FACILITY NUMBER: 198603438
	VISIT DATE: 05/03/2021

NARRATIVE

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Toxins:
Poisons, toxins, and cleaning supplies are not locked and accessible to residents. They need to be locked and inaccessible to residents.

Bedrooms for Residents:
Bedroom A, B, C and D need a chair.
Bedroom B has a hole on the ceiling due to the ceiling light near the door was not properly install.
Bedroom B has a hole on the wall behind the door. It needs to be repaired.
Beds in Bedroom A, B and C are not observed. Applicant stated the potential residents will bring their own bed as they wish when they move in. Applicant needs to be sure residents will have sufficient bedding and linens after they move in.

Linens & Hygiene Supplies:
The required linen/supplies which include pillowcases, mattress pads, blanket and bedspreads are not available and insufficient. Adequate supply of linen, wash cloths and towels are not observed.

Emergency Phone Numbers, Exit Plan, Signages and posters:
Emergency Disaster Plan, Exit Plan, and Labor law poster are not posted near the entrance.

Food Service:
Knives, cutlery and other sharp kitchen utensils are stored in an UN-locked drawer in the kitchen and accessible to residents. They need to be inaccessible to residents.
Food supply is insufficient. The supply does not consist of two days of perishable and two weeks of non-perishable. Administrator needs to maintain adequate food supply of two days of perishable and two weeks of non-perishable according to residents’ dietary needs upon their admissions.
All door magnets are not properly installed which either hanging, not secure to the wall or has an open hole. Each door magnets needs to be repaired.

(- Continued LIC 809 C -)

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2021

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: NAGOMI HOME LLC	FACILITY NUMBER: 198603438
	VISIT DATE: 05/03/2021

NARRATIVE

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Outdoor activity area in backyard:
Outdoor activity area is furnished with chairs and table and in compliance. However, no shaded area in the backyard at the outdoor activity area.
Backyard pavement is under construction and uneven.

Residents & Staff Files:
Locked cabinets for records of staff and clients are not installed and not available. Residents file are not observed.
Staff roster and Resident roster (blank forms) are not available.

Exit:

Component III was not conducted during this visit due to a second visit is needed.

A virtual exit interview was conducted and a copy of this report was provided to applicant. LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, s/he has been instructed to communicate with the CAB Analyst who assigned to his/her application.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2021

LIC809 (FAS) - (06/04)

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