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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603657
Report Date: 11/14/2024
Date Signed: 11/14/2024 02:46:58 PM

Document Has Been Signed on 11/14/2024 02:46 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:
11/14/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:12 PM
MET WITH:Alodia Penas - CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:00 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 Analyst (LPA) Tena Herrera conducted an unannounced Plan of Correction (POC) visit to follow up on a citation that was issued on 10/26/24 during the facility's Annual Inspection. LPA met with Alodia Penas who assisted with the visit.

On 10/26/24 the facility was cited for the following:

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.

During todays visit LPA observed Resident #1 to be residing in Room #3 which is not a designated room for their non-ambulatory status. Only Room #1 is designated for non-ambulatory. Civil penalties will be assessed during todays visit on the above citation in the amount of $400 for dates 11/10/24-11/13/24. Administrator Margie Isidro to relocate Resident #1 to room #3 and send a proof of correction by 11/17/2024.

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.

On 11/5/24 LPA received via email, a copy of Staff #2's Health Screening with negative TB result that was dated 2/29/2024. Proof of Correction (POC) is now cleared for the above citation.


Exit interview conducted and a copy of this report was provided to Alodia Penas.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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 1