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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603521
Report Date: 03/06/2023
Date Signed: 03/06/2023 05:22:46 PM

Document Has Been Signed on 03/06/2023 05:22 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:A PEACEFUL HOME OF COVINAFACILITY NUMBER:
198603521
ADMINISTRATOR:BUGASTO, MYRNA G.FACILITY TYPE:
740
ADDRESS:16025 E BRIDGER ST.TELEPHONE:
(626) 244-9999
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY: 6CENSUS: 5DATE:
03/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:08 AM
MET WITH:Kamaria Noor, Caregiver TIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection. LPA arrived unannounced and met with Staff, Kamaria Noor, who allowed entry. The purpose for the visit was explained. The facility is licensed for residents ages 60 and over. The fire clearance is approved for (5) non-ambulatory residents in rooms #1, 2, 4, and 5. Bedroom #3 is approved for (1) bedridden. There is a hospice waiver approved for 6 residents.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents and medications. Disposals of trash are done immediately after changing a resident. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan posted by the entrance.
Operational Requirements: The facility has a dementia care plan to accept or retain residents with dementia. There are currently 5 non-ambulatory residents residing at the facility. Bedroom #3 is the designated room for (1) bedridden resident only. The facility has the sufficient amount for liability insurance covering injury to residents and guest.
Physical Plant & Environment Safety: There are no pool or bodies of water at the premises. There are 5 bedrooms, 2 bathrooms, living room, dining room, kitchen, and an attached garage. The garage has an additional room allotted for a live-in staff room. Facility has operable smoke and carbon monoxide combo detectors located in each room and hallway. Knives, cleaning solutions, and disinfectants are locked in the cabinets. No firearms or weapons are stored at the facility. LPA measured the hot water temperature in the bathrooms and kitchen sink. The hot water temperature in the bathrooms were measured between 126 -129 degrees F which are above the required range of 105-120 degrees.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2023
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: A PEACEFUL HOME OF COVINA
FACILITY NUMBER: 198603521
VISIT DATE: 03/06/2023
NARRATIVE
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Staffing: There appears to be sufficient staffing at the facility. The administrator's (Thang Duong) certificate expires on 06/02/23. Staff employed are all over the age of 18.
Personnel Records-Training: Staff files are maintained at the facility. Staff have current CPR/first aid training and sufficient on-going training.
Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan.
Resident Rights-Information: The Complaint poster and Residents personal rights are posted by the main entry.
Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability.
Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The food are properly stored in the refrigerator to avoid cross contamination.
Incidental Medical & Dental: The medications are centrally stored and in their original containers. The facility uses the Medication Administration Record (MAR) log to document medications given. During the visit today, LPA reviewed all 5 residents' medication and did not observe the MAR to be completely filled out according to the date administered.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites.
Residents with Special Health Needs: The facility accepts and retains residents with dementia and/or hospice. The staff received training on appropriately caring for residents with dementia, those on hospice, and receiving oxygen. No Smoking - Oxygen in use signs are posted on the doors of residents using oxygen.
During the visit today, LPA observed some deficiencies and are indicated on the LIC809D. Technical advisories were also provided. An exit interview was held. A copy of this report, LIC809D, technical advisory notes, and appeal rights were given to Co-Administrator Elizah Arganosa.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 03/06/2023 05:22 PM - It Cannot Be Edited


Created By: Cynthia D Chan On 03/06/2023 at 04:52 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: A PEACEFUL HOME OF COVINA
FACILITY NUMBER: 198603521

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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 for both of the bathrooms measuring over 120 degree F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/07/2023
Plan of Correction
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The licensee shall ensure the hot water temperature is within the range of 105-120 degrees F at all times. The POC is due on 3/7/23.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2023


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 03/06/2023 05:22 PM - It Cannot Be Edited


Created By: Cynthia D Chan On 03/06/2023 at 04:52 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: A PEACEFUL HOME OF COVINA
FACILITY NUMBER: 198603521

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(a)
Alterations to Existing Buildings or New Facilities
Prior to construction or alterations, all facilities shall obtain a building permit.

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 which an additional staff room was added to the garage space which poses a potential safety risk to persons in care.
POC Due Date: 03/13/2023
Plan of Correction
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The licensee shall submit an updated facility sketch to include the staff room by POC due date 3/13/23.
Type B
Section Cited
CCR
87411(a)
87411 Personnel Requirements - General

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.

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 for all residents' March MAR log which poses a potential health and safety risk to persons in care.
POC Due Date: 03/13/2023
Plan of Correction
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The licensee shall ensure staff handling medications are filling out the MAR log consistently and accurately. An inservice training shall be provided to staff to ensure they are completing the logs by POC due date 3/13/23.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2023


LIC809 (FAS) - (06/04)
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