191221043-6-1-2023-28-AS-EZAA-CSDTKY-20230601144844

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191221043
Report Date: 06/01/2023
Date Signed: 06/01/2023 02:49:02 PM

Document Has Been Signed on 06/01/2023 02:49 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:	HOMES FOR LIFE FOUNDATION WILSON HOUSE		FACILITY NUMBER:	191221043
ADMINISTRATOR:	LIESS, CAROL		FACILITY TYPE:	735
ADDRESS:	54 N. WILSON AVE		TELEPHONE:	(626) 568-3657
CITY:	PASADENA	STATE: CA	ZIP CODE:	91106
CAPACITY: 8		CENSUS: 8	DATE:	06/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:44 AM
MET WITH:	Lerisa Cantos - Facility/House Manager		TIME COMPLETED:	03:28 PM

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Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to Lerisa Cantos the Facility/House Manager and was granted access into the facility. Support Services Coordinator Katrin Silvestro arrived shortly thereafter. There are eight (8) ambulatory developmentally disabled clients who reside in the home. The facility get clients referred to them through the Homes of Life Foundation - Cedars Home which is a transitional housing facility once they finish their program clients which are higher functioning are able to be transferred to this facility, along from other board and care facilities and also from the parents of the clients as well.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention.

Infection Control:

· Infection control practices and Personal Protective Equipment (PPEs) were observed. The Facility administrator Carol Liess advised that she has worked with LPA Mary Flores on submitting and getting her Infection Control Plan approved in the past.

Physical Plant/Environment Safety:

· The facility is a two-story home located in a residential neighborhood that is licensed for a capacity of eight (8) ambulatory clients. It consists of 4 shared client bedrooms, a staff room, a living room, dining room, a kitchen, an office, two (2) shared client bathrooms of which the non-private restroom on the first floor R#1 measured at 118.7 degrees F and second restroom on the second floor R#2 Measured 110.5 degrees F, and a front and back patio area that includes the facility’s washing a drying machines.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

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: HOMES FOR LIFE FOUNDATION WILSON HOUSE	FACILITY NUMBER: 191221043
	VISIT DATE: 06/01/2023

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· The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors are operational. The facility has three (3) fully charged fire extinguisher, one is kept in the kitchen, the second is kept in the office, while the third is located in the main hallway on the second floor of the house. Cleaning supplies and toxic substances are inaccessible to clients in a locked storage area in the back lot of the facility.
· Water temperature readings measured between the required 105 - 120 degrees Fahrenheit.
Operational Requirements:
· The Program Design was reviewed.

· Fire clearance was approved by LA County Fire Department for eight (8) ambulatory developmentally disabled clients.

· Care and supervision to meet the clients’ needs was observed.
Staffing:

· A total of sixteen (16) full-time staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

· Administrator certificate renewal was requested on 2/23/2023 and faxed LPA and invoice showing she has paid her $200 dollars in fees to have it renewed, however she is still awaiting the arrival of the certificate due to a backlog at the moment.

· Five (5) staff files were reviewed for criminal background clearance and training.
· Personnel records have health/TB screenings, CPI training, certifications, and 1st Aid/CPR training.
Client Rights/Information:

· Physician orders were reviewed in client files.

Client Records/Incident Reports:

· Five (5) client files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, nutritional assessments, medication records, and P & I money were reviewed.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

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: HOMES FOR LIFE FOUNDATION WILSON HOUSE	FACILITY NUMBER: 191221043
	VISIT DATE: 06/01/2023

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Food Service:

· The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.

· No restricted Health Care plan required for the clients in the facility.

Health Related Services:

· Clients are assisted with self-administration of prescription and non-prescription medications.

· Five (5) centrally stored resident medication records were reviewed. Centrally stored medications are kept in a safe and locked place not accessible to clients in care. Medications are given according to Physician directions.

Incident Medical and Dental:

· All clients have a Needs and Services Plan, and COVID-19 vaccination cards on file.

· Staff training was on file.

Disaster Preparedness, and Emergency Intervention:

· A posted Emergency Disaster Plan LIC 610D containing emergency evacuation information was observed.

· An emergency drill was last documented and 5/31/2023.

Emergency Intervention:

· No manual restraints or seclusion are used with clients in care.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies that were cited during the inspection. Exit interview was conducted and report provided.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

LIC809 (FAS) - (06/04)

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