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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603671
Report Date: 07/30/2024
Date Signed: 07/30/2024 04:09:23 PM

Document Has Been Signed on 07/30/2024 04:09 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:JOYFUL HEARTS CARE HOMEFACILITY NUMBER:
198603671
ADMINISTRATOR/
DIRECTOR:		LOMEDA, RONAFACILITY TYPE:
740
ADDRESS:11648 FACULTY DRTELEPHONE:
(562) 219-7345
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 6CENSUS: 5DATE:
07/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:07 PM
MET WITH:Caregiver John MacalinoTIME VISIT/
INSPECTION COMPLETED:
04:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christian Gutierrez conducted an unannounced Annual Required Visit at 12:07PM. LPA was met by Care giver John Macalino and explained the purpose of the visit. Administrator Rochel Malaca arrived shortly. Facility is licensed to serve residents over 60 years old six (6) can be non-ambulatory, of which one (1) may be bedridden in room#5. During todays visit it was observed facility had two (2) bedridden residents without approved fire clearance civil penalties assessed.

The facility is a single-story building located in a residential area with five (5) resident bedrooms, three (3) bathrooms, kitchen, dining room, living room, front yard, backyard, and detached garage.

LPA toured the facility and observed the following: Each client bedroom has the required furniture and bedding. There is extra clean linen and towels in a hallway closet. Smoke detectors were observed in each room and throughout the facility and are properly operating. There is 1 carbon monoxide in the hallway and is properly operating. The facility has two (2) fully charged fire extinguishers which is kept in the kitchen and living room. Cleaning supplies and toxic substances were observed to be accessible to clients in cabinet next to kitchen deficiency cited. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 40 degrees F. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. Sharps are locked and placed in cabinet in kitchen. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured between 85.1 -85,2 not in the required range of 105-120 degrees F. The facility does not have a swimming pool or bodies of water on the premises There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction. The garage is clean and has extra supplies.

SEE LIC 809C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/30/2024
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 5
Document Has Been Signed on 07/30/2024 04:09 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 07/30/2024 at 03:11 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: JOYFUL HEARTS CARE HOME
FACILITY NUMBER: 198603671

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2024

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 comet cleaner,lysol spary, and scissors were left unlocked in drawer accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2024
Plan of Correction
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Caregiver removed items and locked in another cabinet. Administartor will conduct training and email a copy to LPA.
Type A
Section Cited
CCR
87606(c)
Care of Bedridden Residents
(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a).

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 in one (1) out of five (5) residents by operating out of required scope fire clearance only approved for one (1) bedridden in room number five facility has two (2) bedridden, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2024
Plan of Correction
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Obtain proper documentation and fire clearance. Administartor will email all documents to LPA.
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:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 07/30/2024 04:09 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 07/30/2024 at 03:11 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: JOYFUL HEARTS CARE HOME
FACILITY NUMBER: 198603671

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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 bathroom #1 85.2 bathrrom #2 85.1 and bathroom #3 85.2 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/13/2024
Plan of Correction
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Administrator adjusted water temperture during visit and will complete a weekly log and send via email to LPA.
Type B
Section Cited
CCR
87412(a)
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:

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 Administartor did not have file at facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/13/2024
Plan of Correction
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Administartor will email complete file to LPA.
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:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/30/2024 04:09 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 07/30/2024 at 03:11 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: JOYFUL HEARTS CARE HOME
FACILITY NUMBER: 198603671

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

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 facility did not have any emergency drill at facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/13/2024
Plan of Correction
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Administrator will conduct emergency drills and email a copy to LPA.
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

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 in two (2) out of five (5) residents did not have physician orders for bed rails which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/13/2024
Plan of Correction
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Administartor will obtain physicians orders for bedrails and email to LPA.
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:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024


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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: JOYFUL HEARTS CARE HOME
FACILITY NUMBER: 198603671
VISIT DATE: 07/30/2024
NARRATIVE
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Three (3) Staff files were reviewed and included Criminal clearance record, CPR/training, and health screening with TB. Administrator did not have file at facility deficiency cited. Five (5) Client files were reviewed and included physicians report, TB clearance. Fire/earthquake drill was not conducted deficiency cited. Infectious control plan was reviewed. The medications are centrally stored and locked in a cabinet in kitchen The facility uses the Medication Administration Record (MAR) log to document medications given. LPA reviewed medications for all clients, and they are being administered as prescribed by the physician.

Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided to Rochel Malaca.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
LIC809 (FAS) - (06/04)
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