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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191222591
Report Date: 07/06/2023
Date Signed: 07/06/2023 12:47:33 PM

Document Has Been Signed on 07/06/2023 12:47 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-MADISON HOUSEFACILITY NUMBER:
191222591
ADMINISTRATOR:CAROL LIESSFACILITY TYPE:
735
ADDRESS:489 N. MADISON AVENUETELEPHONE:
(626) 583-8019
CITY:PASADENASTATE: CAZIP CODE:
91101
CAPACITY: 9CENSUS: 7DATE:
07/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Imelda Jonson - caregiverTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE tool. LPA met with Imelda Jonson - caregiver and explained the reason for the visit.

Facility is a two-story home licensed to serve 9 adults between the ages of 18 to 59 years old, ambulatory only. Facility has 5 client bedrooms, 2 client bathrooms, 1 staff bedroom with a private staff bathroom, a kitchen, laundry, living room and dining/office room and a detached garage.

LPA conducted a tour of the facility with staff and observed the following:
Facility's outside is in good condition, no large bodies of water observed and has a front porch or backyard. A shaded sitting area is in the backyard. Facility has sufficient non-perishable (2 days) and perishable (7 days) foods. Kitchen's refrigerator was observed and thermometer read at 60 degrees F, and freezer's at 0 degrees. Living room/dining room/kitchen and laundry room are in good repair. Client bedrooms (5) were observed, each has the required furniture and bedding supplies. Bedroom #5 was observed with a hole of about 2x2 inches in the wall covered with clear tape. Bathrooms (2) were observed in good repair and water temperature was tested between 116-120 degrees F., which is within the required 105-120 degrees F. Cleaning supplies and sharps were observed locked in kitchen's cabinet. Additional food supplies were observed in the garage. Medication is locked inside caregiver's bedroom. LPA reviewed medication, P&I money, and files for 5 clients, and 5 staff files. Emergency disaster plan LIC610D(10/03) last updated on 8/19/20. Last fire drill was conducted on 5/31/23. Fire extinguishers were last checked on 9/28/22. Smoke/Carbon monoxide detectors were tested and in working condition.
Administrator certificate was observed for Carol Liess #6025209735 exp. date: 2/25/23, department received renewal 5/4/23 pending renewal. HIV/TB training on file is dated 10/8/99 per requirements it should be updated every two years.
Deficiencies are noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Katrin Silvestro Services Coordinator 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: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2023
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 3
Document Has Been Signed on 07/06/2023 12:47 PM - It Cannot Be Edited


Created By: Mary G Flores On 07/06/2023 at 11:57 AM
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-MADISON HOUSE
FACILITY NUMBER: 191222591

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/06/2023

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
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Based on observation, the licensee did not comply with the section cited above in client bedroom #5 has a hole of about 2x2 inches in the wall covered with clear tape which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/20/2023
Plan of Correction
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Administrator will contact maintenance and have the hole repair and submit a picture to the department by POC due date 7/20/23.
Type B
Section Cited
CCR
85064(k)
Administrator Qualifications and Duties
(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years.

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 last training on file for administrator on HIV/TB is dated 10/8/99 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/20/2023
Plan of Correction
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Administrator will submit a copy of HIV/TB training to the department by POC due date 7/20/23.
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: 07/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/06/2023 12:47 PM - It Cannot Be Edited


Created By: Mary G Flores On 07/06/2023 at 11:57 AM
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-MADISON HOUSE
FACILITY NUMBER: 191222591

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85076(d)(3)
Food Service
(3) Refrigerators shall be large enough to accommodate required perishables and shall maintain a maximum temperature of 45 degrees F (7.2 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 refrigerator's temperature was observed at 60 degrees F., which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/20/2023
Plan of Correction
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Administrator will contact maintenance to adjust the temperature on the refrigerator, and will maintain a log. Administrator will submit a copy of the log from 7/7/23--7/20/23 and a picture of thermomether in refrigerator by POC due date 7/20/23.
Type B
Section Cited
HSC
1565(a)

a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

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 version 10/03 is not the current version required and was last updated on 8/19/20 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/20/2023
Plan of Correction
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Emergency disaster plan will be updated to current version (12/21) and will submit a copy to the department by POC due date 7/20/23.
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: 07/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2023


LIC809 (FAS) - (06/04)
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