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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191290706
Report Date: 07/11/2022
Date Signed: 07/11/2022 04:30:10 PM

Document Has Been Signed on 07/11/2022 04:30 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
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: 9DATE:
07/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:09 AM
MET WITH:Taylor Surtherland, and Myrna Stevenson Direct Support StaffTIME COMPLETED:
04:36 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 Analysts (LPA) Alberto Lopez conducted an unannounced site visit for the annual inspection. Upon arriving at the facility LPA met with Tayor Sutherland and Myrna Stevenson, Direct support staff and explained the purpose of the visit. Administrator was not available for the inspection due to illness. The facility is licensed to serve ambulatory only. Facility is a residential home to clients with Developmental Disabilities, Level 2. Administrator certificate expired on 01/08/22. Last fire drill was on 03/25/22
The facility is located in a residential area. A tour of the single-story facility includes: Living room, kitchen, dining area, laundry area, 7 client bedrooms, 1 staff room, office, and an attached garage.
The following were observed/inspected:
· COVID-19 signs are posted at the entrance. Visitors are screened in the main entrance and a log is kept.
· Infection control signs and other COVID-19 signs are posted throughout the facility in the bathrooms, kitchen, and hallway to promote handwashing, cough/sneeze etiquette, and physical distancing.
· Facility does not have one designated isolation room as the resident have private rooms where they can isolate
· Seven client rooms, common areas, bathrooms, and outdoor physical plant was inspected.
· Rooms were not equipped with alcohol-based hand sanitizer but available at facility.
· Seven (7) centrally stored client medication records were reviewed.
· Staff responsible for direct care and supervision were observed wearing masks.
· Clients were observed wearing masks and adhering to public health social distance guidelines.
· Sufficient supply of perishable food for 2 days & non-perishable foods for 7 days were observed.
· A posted Emergency Disaster Plan was observed at facility.
· PPE's were observed.
· Staff and resident files were not reviewed during today's visit.
Deficiencies cited per Title 22 Health and safety code, See 809D for details.
Exit interview was conducted with Myrna Stevenson, Direct support staff. A copy of
the report was provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2022
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 07/11/2022 04:30 PM - It Cannot Be Edited


Created By: Alberto Lopez On 07/11/2022 at 03:59 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: HAMILTON HOUSE
FACILITY NUMBER: 191290706

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2022

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. Face of refrigerator when water dispenses is rusted and metal is deteriorating which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2022
Plan of Correction
1
2
3
4
Licensse shall repair or replace refrigerator and send photo as proof of correction to LPA by POC date
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

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. One window screen in the back of the home does not fit properly and has a gap which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2022
Plan of Correction
1
2
3
4
Licensee will repair or replace window screen and send photo as 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:Stefanie Coronel
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/11/2022 04:30 PM - It Cannot Be Edited


Created By: Alberto Lopez On 07/11/2022 at 04:17 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: HAMILTON HOUSE
FACILITY NUMBER: 191290706

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85064.3(d)

(d) To apply for recertification prior to the expiration date of the certificate, the certificate holder shall submit to the Department's Administrator Certification Section, post-marked on, or up to ninety (90) days before, the certificate expiration date:


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above, Administrator certificate expired 01/08/2022 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2022
Plan of Correction
1
2
3
4
Licensee will provide proof of the following to LPA by POC date:

(1) completed Application for Administrator Certification form LIC 9214.
(2) Evidence of completion of forty (40) continuing education hours as specified in Section 85064.3(a) above.

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:Stefanie Coronel
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2022


LIC809 (FAS) - (06/04)
Page: 3 of 3