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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603657
Report Date: 10/26/2024
Date Signed: 10/26/2024 12:55:37 PM

Document Has Been Signed on 10/26/2024 12:55 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:HOME 'R USFACILITY NUMBER:
198603657
ADMINISTRATOR/
DIRECTOR:		ISIDRO, MARGARITAFACILITY TYPE:
740
ADDRESS:10423 TRABUCO ST.TELEPHONE:
(562) 376-0298
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 6CENSUS: 2DATE:
10/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Margie Isidro - AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Margie Isidro and explained the purpose for today’s visit. The facility is licensed to serve 6 Ambulatory Adults Age 60 and over, (2 of which may be non-ambulatory in Room #1). There is a Hospice waiver for 2 residents.

The facility is a single-story home located in Bellflower, Ca. A tour of the facility includes: 4 bedrooms (2 of which are used for Administrator and Daughter who live in the facility), 2 full bath (1 full bath is inside room occupied by administrator), 1 1/2 bath, living room, dining area, kitchen, attached garage with laundry, front yard and back yard. There is an empty ADU in the back yard that administrator stated will be used by staff and/or storage, Administrator stated the permits for the ADU were sent to LPA Pena, this will be verified during upcoming work week.

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


Infection Control: Facility has sufficient PPE supplies and has 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.
Planned Activities: Facility provides scheduled activities and have 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.
Residents with Special Health Needs: There currently are no residents on hospice at the facility.

(Continued on LIC809-C)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2024
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: HOME 'R US
FACILITY NUMBER: 198603657
VISIT DATE: 10/26/2024
NARRATIVE
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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. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged. After file review it was observed that Resident #2 is Non-Ambulatoy and is residing in Room #3, per license and fire clearance non-ambulatory residents are approved for room #1 only, citation will be issued and detailed on LIC809-D.
Staffing: There are currently 2 staff for facility, Administrator stated since there are only 2 residents with little care needs there is no need for additional staff, LPA advised Administrator that additional staff may need to be hired if more residents are admitted to meet their needs.
Personnel Records-Training: Staff has criminal record clearance, current First-Aid/CPR/AED training along with training in postural supports, medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 2 staff files, and observed that Staff #2 was missing their Health Screening and TB results from file, citation will be issued and detailed in LIC809-D. Administrator Margie Isidro has a valid certificate that was verified through the CCL website with an expiration date of 2/2/26.
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.
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.
Incidental Medical & Dental: Medication is properly labeled and are centrally stored in a cabinet and are in their original containers. LPA reviewed 1 residents’ medications and there were no issues observed.
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Last fire/earthquake drill was conducted on 9/1/24.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during todays visit will be documented on LIC809-D. Exit interview held and a copy of the report will be emailed to Margie Isidro.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/26/2024 12:55 PM - It Cannot Be Edited


Created By: Tena Herrera On 10/26/2024 at 12:26 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: HOME 'R US
FACILITY NUMBER: 198603657

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87204(a)
Limitations -Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.

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 as Resident #1 is currently residing in Room #3, per physician report resident is Non-Ambulatory and the only room licensed for Non-Ambulatory is Room #1 (this room is currently occupied by Administrator as she lives in facility), this poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/09/2024
Plan of Correction
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Administrator/Licensee to relocate Resident #1 to Room #1 by POC Due Date, and send LPA photos of changes via email. tena.herrera@dss.ca.gov
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as Staff #2's file was missing the required health screening report and TB result, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/09/2024
Plan of Correction
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Administrator/Licensee to provide LPA with a copy of Staff #2's Health Screening report and TB result by POC due date via email. tena.herrera@dss.ca.gov
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: 10/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2024


LIC809 (FAS) - (06/04)
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