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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221667
Report Date: 09/21/2023
Date Signed: 09/21/2023 01:40:50 PM

Document Has Been Signed on 09/21/2023 01:40 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
Lookup Error,
, CA
FACILITY NAME:ALMA HOUSEFACILITY NUMBER:
191221667
ADMINISTRATOR:CORREA. CARLOSFACILITY TYPE:
735
ADDRESS:1123 ALMA STREETTELEPHONE:
(818) 502-0929
CITY:GLENDALESTATE: CAZIP CODE:
91202
CAPACITY: 6CENSUS: DATE:
09/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:27 AM
MET WITH:Danika-Jean Lewis, Administrator TIME COMPLETED:
01:53 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) Alberto Lopez made an unannounced annual inspection visit. LPA met with DSP Josefina Sandoval and Danika-Jean Lewis, Administrator arrived a short time later and assisted with the visit. LPA explained the purpose of today's visit.

This is a one story Adult Residential Facility (ARF) facility consisting of 4 client bedrooms 3 bathrooms, kitchen, dining room, activities room, laundry room, storage room, medication closet, staff office and outdoor shaded activity area. This facility is licensed at a capacity of 6 clients and today's census was 6.

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

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies. an Infection Control Plan was not posted at the facility but completed during visit.


Physical Plant & Environment Safety: LPA observed 4 client bedrooms, 2 are shared and closet/drawer space to accommodate each client comfortably was available. There are 3 bathrooms at the facility, and one is undergoing a renovation. The facility is free of debris/hazards and the outdoor passageways and activity area is full of construction equipment, that is removed daily, as the facility is renovating one bathroom. Two rooms are missing chairs. One restroom toilet is in disrepair and the sink backs up. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. The hot water temperature was tested, and temperature measured between 132.4-132.9 degrees F which is not within required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are inaccessible to clients. The last Fire/Emergency Drill was over 5 months ago. Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguishers were observed and recently inspected.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2023
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 10
Document Has Been Signed on 09/21/2023 01:40 PM - It Cannot Be Edited


Created By: Alberto Lopez On 09/21/2023 at 01:09 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
,
, CA

FACILITY NAME: ALMA HOUSE
FACILITY NUMBER: 191221667

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. Hot water temperature measured between 132.4 -132.9 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/22/2023
Plan of Correction
1
2
3
4
Administrator will adjust water and send proof to LPA by POC date.
Type A
Section Cited
CCR
80065(f)(4)
Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance. (4) Assistance with prescribed medications which are self-administered.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. Staff who administer medications do not have the required training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/22/2023
Plan of Correction
1
2
3
4
Administrator will send proof that all staff that administer medications have the proper training.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2023


LIC809 (FAS) - (06/04)
Page: 2 of 10
Document Has Been Signed on 09/21/2023 01:40 PM - It Cannot Be Edited


Created By: Alberto Lopez On 09/21/2023 at 01:09 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
,
, CA

FACILITY NAME: ALMA HOUSE
FACILITY NUMBER: 191221667

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. Resident's room knobs are missing from dresser, two drawers are missing from kitchen cabinet which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
1
2
3
4
Administrator will repair the dresser and kitchen drawers by POC date and send proof to LPA.
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. The toilet in one restroom does not operate properly as the flushing mechanism is broken and the sink back up. ] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
1
2
3
4
Administrator will repair the bathroom sink and toilet by POC date and send proof to LPA by POC date.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2023


LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 09/21/2023 01:40 PM - It Cannot Be Edited


Created By: Alberto Lopez On 09/21/2023 at 01:09 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
,
, CA

FACILITY NAME: ALMA HOUSE
FACILITY NUMBER: 191221667

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(2)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (2) Bedroom furniture including, in addition to (c)(1) above, for each client, a chair, a night stand, and a lamp or lights necessary for reading.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
1
2
3
4
Administrator will provide chairs for the two residents by POC date and send proof to LPA.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2023


LIC809 (FAS) - (06/04)
Page: 4 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: ALMA HOUSE
FACILITY NUMBER: 191221667
VISIT DATE: 09/21/2023
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
26
27
28
29
30
31
32
Operational Requirements: Facility is in compliance.

Staffing: There appears to be sufficient staffing in the facility. CPR/First aid certificates are on file. Administrator Danika-Jean Lewis certificate expires on 12/01/2023.

Personnel Records-Training: Staff has criminal record clearance. Staff files are maintained at the facility located in a locked cabinet in the staff office room. Staff have current CPR/first aid training.


Client Rights-Information: Client personal rights poster is posted in the facility.
Client Records-Incident Reports: Client files are kept in a secure location within the facility office and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. IPP was recently updated for all 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.
Health Related Service: Staff designated to administer medication do not the proper annual training on file. Medication is properly labeled and are centrally stored in a locked medication cabinet located in the staff office All medications are properly labeled and in their original containers. During the visit today, LPA reviewed all 6 clients' medications, all medication is administered according to doctor’s orders. PRN authorizations letters are on file
Incidental Medical & Dental: All medications for clients are kept locked and inaccessible to other clients.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites.
Emergency Intervention: Clients at this facility do not have restraints nor do they require the use de-escalation techniques.

Deficiencies cited during today's visit. Technical advisories also provided.

An exit interview was conducted and a copy of this report and appeal rights were provided to Administrator Danika-Jean Lewis

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
LIC809 (FAS) - (06/04)
Page: 10 of 10