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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191222591
Report Date: 05/30/2024
Date Signed: 05/30/2024 03:28:44 PM

Document Has Been Signed on 05/30/2024 03:28 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/
DIRECTOR:		CAROL LIESSFACILITY TYPE:
735
ADDRESS:489 N. MADISON AVENUETELEPHONE:
(626) 583-8019
CITY:PASADENASTATE: CAZIP CODE:
91101
CAPACITY: 9CENSUS: 8DATE:
05/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:49 AM
MET WITH:Imelda Jonson - Facility ManagerTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Imelda Jonson 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, a balcony, 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 Imelda Jonson and observed the following:
Facility is in good repair indoor and outdoor. Living room has a fireplace that has been covered. Dining room/office area is clean. Kitchen is clean, in good repair, cleaning supplies are stored inaccessible to clients under the sink, and sharps are inaccessible in a drawer. Refrigerators/Freezers are maintain at 35 degrees F., and 0 degrees F. Food supplies are sufficient for at least 2 days of perishables and 7 days of non-perishables. Laundry area is clean. Five client rooms were observed clean, with the required furniture, sufficient lighting, and bedding supplies. Two bathrooms were observed clean and in good repair. Water temperature was tested between 120.3-122.2 degrees F., which is not within the required 105-120 degrees F. Facility has two indoor stairways. No evacuation emergency chairs were observed. Backyard is clean and provides a shaded seating area. No large bodies of water were observed.
LPA reviewed medication, P&I money, and medication for 5 clients and 5 staff files. Administrator certificate was observed for Carol Leiss #6025209735 exp. date: 2/25/25. Emergency Disaster Plan (10/03) was reviewed and does not meet Health and Safety Code requirements. Infection Control Plan was reviewed.

LPA interviewed 3 clients and 2 staff.

Deficiencies were noted per Title 22 Regulations. Exit interview was conducted with Imelda Jonson 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: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/30/2024
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 3
Document Has Been Signed on 05/30/2024 03:28 PM - It Cannot Be Edited


Created By: Mary G Flores On 05/30/2024 at 02:59 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-MADISON HOUSE
FACILITY NUMBER: 191222591

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2024

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
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Based on observation, the licensee did not comply with the section cited above in bathroom #1 water temperature tested at 122.2 degrees F., which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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Licensee will adjust water temperature to meet the requirement of 105-120 degrees F., and will certify in writing that will ensure water temperature is within the required 105-120 degrees F., by POC due date 5/31/24 and will provide a daily log of water temperature for the next 7 days by 6/6/24.
Section Cited
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: 05/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 05/30/2024 03:28 PM - It Cannot Be Edited


Created By: Mary G Flores On 05/30/2024 at 02:59 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-MADISON HOUSE
FACILITY NUMBER: 191222591

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 LIC 610(10/03) which does not meet the requirements of LIC 610(12/21) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2024
Plan of Correction
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Administrator will submit a copy of LIC 610D (12/21) to the department by POC due date 6/6/24.
Section Cited
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: 05/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2024


LIC809 (FAS) - (06/04)
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