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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603572
Report Date: 09/09/2024
Date Signed: 09/09/2024 04:59:23 PM

Document Has Been Signed on 09/09/2024 04:59 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:PALAZZO OF DOWNEY, INC., THEFACILITY NUMBER:
198603572
ADMINISTRATOR/
DIRECTOR:		CARRILLO, ROWENA MARANTALFACILITY TYPE:
740
ADDRESS:9276 DOWNEY AVETELEPHONE:
(562) 659-7586
CITY:DOWNEYSTATE: CAZIP CODE:
90240
CAPACITY: 6CENSUS: 4DATE:
09/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Rowena Marantal Carrillo - AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Rowena Marantal Carrillo - Administrator and explained the purpose for today’s visit. The facility is licensed to serve 6 Ambulatory Residents ages 60 and above, and a hospice waiver for (4). The facility currently has 2 residents on Hospice.

The facility is a two-story home located in Downey, Ca. A tour of the facility includes: 1st floor: 2 resident bedrooms, 1 full bath, 1 1/2 bath, kitchen dining area, family room, living room, pantry, laundry room, closets, attached garage, front yard and back yard. 2nd (frontal) floor: 5 bedrooms (2 are resident rooms with private bath, 3 are staff rooms with bath), staff bath. 2nd (rear) floor: 2 staff bedrooms and 1 staff bath.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit todays visit and the initial visit and observed the following:


Infection Control: Staff are cleaning and disinfecting throughout the day and have an Infection Control Plan maintained at the facility.
Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with required Infection Control Plan and facility maintains the required liability insurance.
Staffing: There appears to be sufficient staffing at all times in the facility.
Personnel Records-Training: Staff has criminal record clearance, and ongoing training are documented in personnel files. LPA reviewed 4 staff files and 3 out of the 4 staff files reviewed were missing their first-aid certificates, citation will be detailed in the LIC809-D. Administrator Rowena Marantal Carrillo administrator certificate expires 6/24/2025.
Resident Records-Incident Reports: Resident files are kept in a secure location and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 4 Resident Files with no issues observed.
(Continued on LIC809-C)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2024
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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Document Has Been Signed on 09/09/2024 04:59 PM - It Cannot Be Edited


Created By: Tena Herrera On 09/09/2024 at 03:49 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: PALAZZO OF DOWNEY, INC., THE
FACILITY NUMBER: 198603572

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 as during tour LPA observed a empty can of disinfectant in an unlocked cabinet in residents downstairs restroom, also Laundry room was observed to be unlocked with door open during visit which poses an immediate health, safety or personal rights risk to persons in care. (tena.herrera@dss.ca.gov)
POC Due Date: 09/10/2024
Plan of Correction
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*administrator threw away empty disinfectant can and closed/locked laundry room door during tour*
Licensee/Administrator to review regulation 87309 in its entirety and sign the LIC9098 provided during todays visit and email LIC9098 to LPA by 9/16/24, by signing form Licensee/Administrator is stating that regulation has been reviewed and moving forward regulation will be followed by all staff.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 as during tour LPA observed unlocked personal medication/suppliments that belong to staff in an unlocked kitchen cabinet also LPA observed medication cabinet to have keys on cabinet door making medications accessible to residnets, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/10/2024
Plan of Correction
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*Administrator removed stafff medication/supplements from unlocked cabinet during tour and placed in locked cabinet, also Administrator locked medication and removed keys from cabinet lock*
Licensee/Administrator to review regulation 87465 in its entirety and sign the LIC9098 form that was provided during visit, and email signed form to LPA by 9/16/24, by signing form Licensee/Administrator is stating that the regulation was reviewed and moving forward all staff will comply with regulation.
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:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/09/2024 04:59 PM - It Cannot Be Edited


Created By: Tena Herrera On 09/09/2024 at 04:40 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: PALAZZO OF DOWNEY, INC., THE
FACILITY NUMBER: 198603572

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview with administrator, the licensee did not comply with the section cited above as 3 out of the 4 staff files reviewed were missing their valid First-Aid training certificates, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2024
Plan of Correction
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*Administrator stated that there is a scheduled training for this weeked, in which all staff will receive their first aid training certificates*
Administrator/Licensee to have the 3 staff and all other staff that are missing First-Aid training, complete the required training and email LPA a copy of the valid certificates by POC due date. (tena.herrera@dss.ca.gov)
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:David Sicairos
LICENSING EVALUATOR NAME:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024


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: PALAZZO OF DOWNEY, INC., THE
FACILITY NUMBER: 198603572
VISIT DATE: 09/09/2024
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Physical Plant & Environment Safety: LPA toured facility, residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The front yard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested throughout the facility and measured within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked and are inaccessible to residents, however, during visit LPA observed a empty can of disinfectant in an unlocked cabinet in residents downstairs restroom, also Laundry room was observed to be unlocked with door open during visit making disinfectants/cleaning supplies accessible to residents. citation issued and detailed on LIC809-D. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged. Last fire/disaster/earthquake drill was conducted on 9/1/24.
Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman.
Planned Activities: Facility has a variety of activities to choose from within the facility. There is an outdoor activity area available for the residents.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Incidental Medical & Dental: Medication is properly labeled and are centrally stored in a closet and are in their original containers. LPA reviewed 4 residents’ medications during visit. LPA observed staffs personal medication/supplements in an unlocked kitchen cabinet along with medication cabinet being unlocked with key hanging from cabinet making medication accessible to residents, citation issued on LIC809-D.
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites.
Residents with Special Health Needs: There are no bedridden or residents with postural supports at this facility. The facility currently has 2 residents on Hospice

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit will be detailed on the LIC809-D.

Exit interview held and a copy of the report and appeal rights were provided to Rowena Marantal Carrillo.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024
LIC809 (FAS) - (06/04)
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