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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191290706
Report Date: 08/04/2021
Date Signed: 08/05/2021 08:30:23 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:HAMILTON HOUSEFACILITY NUMBER:
191290706
ADMINISTRATOR:PETERSON, JANICEFACILITY TYPE:
735
ADDRESS:739 W. GLENOAKS BLVD.TELEPHONE:
(818) 502-9188
CITY:GLENDALESTATE: CAZIP CODE:
91202
CAPACITY:11CENSUS: 5DATE:
08/04/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Samadra EmbryTIME COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Nina Galarza and Nune Margaryan conducted an unannounced site visit for the annual inspection. Upon arriving at the facility LPA met with Samadra Embry and explained the purpose of the visit. The facility is licensed to serve ambulatory only. Facility is a residential home to clients with Developmental Disabilities, Level 2.

The facility is located in a residential area. A tour of the single-story facility includes: Living room, kitchen, dining area, laundry area, 5 client bedrooms, 1 staff room, office, and an attached garage.

During today’s visit, LPA observed the following: Licensee is not operating beyond the conditions and limitations specified on the license, including the capacity. There are no pools or large bodies of water on the premises. There are no firearms on the premises. A comfortable temperature for clients is maintained. Lamps or lights in all rooms to ensure the comfort and safety were observed. All toilets, hand washing and bathing facilities is safe, sanitary and in operating condition. Hygiene products such as feminine napkins, non-medicated soap, toilet paper, toothbrush, toothpaste, and comb are readily available. All foods are selected, stored, prepared and served in a safe and healthful manner. Nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days were observed. Freezers and refrigerators are clean, and maintain temperatures. Sufficient staff as necessary to ensure provision of care and supervision to meet client needs were observed. Staff have a criminal record clearance. Initial Needs and Services Plan is updated. Each client record contains the Needs and Service Plan and a Mental Health Intake Assessment. Clients list of their Personal Rights were observed. LPAs were allowed to enter the facility to conduct the inspection. All medications are labeled and maintained in compliance with label instructions and State and Federal law. Medications are safe, locked and inaccessible.

CONTINUED 809-C
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Nina GalarzaTELEPHONE: 323-981-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HAMILTON HOUSE
FACILITY NUMBER: 191290706
VISIT DATE: 08/04/2021
NARRATIVE
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The following deficiencies were observed by LPAs at time of visit:
  • LPAs observed several gallons of paint outside and inside garage and garage area, cleaning chemicals under the sink accessible to clients, knife in back yard, shovel by side yard/walk way area, several knives in kitchen accessible to residents.
  • LPAS tested hot water temperature in client bathroom of 133.5 degrees Fahrenheit
  • LPAs observed indoor emergency exit passageway obstructed by 3 ladders, chair, vacuum cleaner storage box, industrial light bulbs, and ironing board.
  • LPAs observed back area behind garage and client room 5, with a chair, recyclables and other miscellaneous items obstructing walkway.
  • LPAS observed missing medication for C1, CHANTIX 1 MG TABLET AND CHANTIX 0.5MG TABLET


Per Title 22 Regulations, the deficiencies observed are documented on LIC809D. Failure to correct the deficiencies may result in civil penalties.

An exit interview was conducted and a copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Nina GalarzaTELEPHONE: 323-981-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HAMILTON HOUSE
FACILITY NUMBER: 191290706
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPAs observed several gallons of paint outside and inside garage and garage area, cleaning chemicals under the sink accessible to clients, knife in back yard, shovel by side yard/walk way area, several knives in kitchen accessible to residents. Based on observation, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2021
Plan of Correction
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Several gallons of paint outside and inside garage and garage area were removed from the premises at time of visit by administrator. Cleaning chemicals under the sink that were accessible to clients, knife in back yard, shovel by side yard/walk way area, several knives in kitchen accessible to residents were removed and locked in a closet by administrator and staff at time of visit. No further action needed.
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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LPAS tested hot water temperature in client bathroom of 133.5 degrees Fahrenheit. Based on observation the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2021
Plan of Correction
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Administrator will self-certify temperature to be compliant and email to LPA Nina Galarza 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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Nina GalarzaTELEPHONE: 323-981-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HAMILTON HOUSE
FACILITY NUMBER: 191290706
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPAS observed missing medication for C1, CHANTIX 1 MG TABLET AND CHANTIX 0.5MG TABLET. Based on observation, interview,record review, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2021
Plan of Correction
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Administrator will provide Discontinue order for medication, provide medication missing or remove medication off Medication Administration Record.
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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Nina GalarzaTELEPHONE: 323-981-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2021
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HAMILTON HOUSE
FACILITY NUMBER: 191290706
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPAs observed indoor emergency exit passageway obstructed by 3 ladders, chair, vacuum cleaner storage box, industrial light bulbs, and ironing board. LPAs observed back area behind garage and client room 5, with a chair, recyclables and other miscellaneous items obstructing walkway. 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: 08/09/2021
Plan of Correction
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Administrator will provide picture of removed items to LPA Nina Galarza via email.
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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Nina GalarzaTELEPHONE: 323-981-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5