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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221043
Report Date: 04/02/2024
Date Signed: 04/02/2024 02:48:42 PM

Document Has Been Signed on 04/02/2024 02:48 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 HOUSEFACILITY NUMBER:
191221043
ADMINISTRATOR:LIESS, CAROLFACILITY TYPE:
735
ADDRESS:54 N. WILSON AVETELEPHONE:
(626) 568-3657
CITY:PASADENASTATE: CAZIP CODE:
91106
CAPACITY: 8CENSUS: 8DATE:
04/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:Lerissa Cantos - House ManagerTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA)s Mary Flores and Christian Gutierrez conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Larissa Cantos and explained the reason for the visit.

Facility is licensed to serve 8 ambulatory clients between the ages of 18-59 years old. Facility is a two story house with 4 client bedrooms, 2 clients bathroom, 1 live-in staff bedroom, 1 staff bathroom, living room, dining room, kitchen, an office, detached garage, front and back porch with laundry room area, and a shaded outdoor sitting area.

LPAs conducted a tour of the facility with Larissa Cantos and observed the following:
Facility was observed in good repair inside and outside. Living room was observed to have a fireplace that is cover. Dining was observed as their activity area with supplies and sufficient sitting area. Kitchen was observed clean, food supplies were observed LPAs sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables. Sharps were observed locked in a drawer. Refrigerators and freezers were observed. Freezers were observed at 20 degrees F., which is not the required zero or under degrees F. Cleaning supplies were observed locked in the storage by garage. Each room (4) had sufficient lighting, required furniture, and bedding supplies. Bathrooms (2) are in working condition, were observed with skid mats and grab bars (home service 60 and over clients), water temperature was tested between 108.3-113.8 degrees F., which is within the required 105-120 degrees F. Carbon monoxide/Smog detectors were tested and in working condition. No large bodies of water were observed. Backyard patio has a shaded sitting area. LPAs did not observed evacuation chairs in each stairwell.

LPAs reviewed 5 client files and medication. P&I money for 2 clients was reviewed. Five staff files were reviewed and emergency annual training was not observed. Infection control plan and emergency disaster plan were reviewed. Emergency disaster plan (version 10/03) was last updated on 8/30/19 and is missing some of the components do not meet the most current emergency disaster plan.(CONTINUED ON LIC 809C)
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/02/2024
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 04/02/2024 02:48 PM - It Cannot Be Edited


Created By: Mary G Flores On 04/02/2024 at 02:01 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: HOMES FOR LIFE FOUNDATION WILSON HOUSE
FACILITY NUMBER: 191221043

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85076(d)(2)
Food Service
(2) Freezers shall be large enough to accommodate required perishables and shall be maintained at a temperature of zero degrees F (-17.7 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 in freezer in the storage by garage and in the kitchen, both read at 20 degrees F., which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/09/2024
Plan of Correction
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Administrator will ensure temperature is under zero degrees F. for both freezer and will submit a picture of thermometer in the freezer by POC due date 4/9/24.
Section Cited
Food Service
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 04/02/2024 02:48 PM - It Cannot Be Edited


Created By: Mary G Flores On 04/02/2024 at 02:01 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: HOMES FOR LIFE FOUNDATION WILSON HOUSE
FACILITY NUMBER: 191221043

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(b)
Other Provisions
(b) If a facility employs staff, the facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster.

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 no annual training for emergency or disaster was observed for staff during file review for all 5 staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/16/2024
Plan of Correction
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Administrator will provide emergency disaster training for staff and will provide a copy of log-in sheet with topic and duration of training by POC due date 4/16/24.
Type B
Section Cited
HSC
1565(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee, administrator, or regulated individual shall sign and date the documentation to indicate that the plan has been reviewed and updated as necessary.

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 Emergency Disaster Plan was last updated on 8/30/19 version 10/03 which is not current which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/16/2024
Plan of Correction
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Administrator will submit a copy of Emergency Disaster Plan version (12/21) or a version that meets the requiremets to the department by POC due date 4/16/24.
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:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024


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: HOMES FOR LIFE FOUNDATION WILSON HOUSE
FACILITY NUMBER: 191221043
VISIT DATE: 04/02/2024
NARRATIVE
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LPAs interviewed 3 clients and 1 staff.

Deficiencies were noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with Lerissa Cantos and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024
LIC809 (FAS) - (06/04)
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