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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191591729
Report Date: 09/02/2021
Date Signed: 09/08/2021 08:52:02 AM

Document Has Been Signed on 09/08/2021 08:52 AM - 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:C.M.A.FACILITY NUMBER:
191591729
ADMINISTRATOR:AMARSINGHE, SWARNAFACILITY TYPE:
735
ADDRESS:18432 GRIDLEY RD.TELEPHONE:
(562) 860-2479
CITY:ARTESIASTATE: CAZIP CODE:
90701
CAPACITY: 46CENSUS: 46DATE:
09/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Staff / Nellie Holmes
Administrator / Swarna Amarsinghe		TIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted a site visit for the Required - 1 Year inspection. Upon arriving at the facility, LPA met with Staff / Nellie Holmes and was later joined by the Administrator / Swarna Amarsinghe who assisted with the visit. The facility is licensed to serve for a capacity of forty six (46) clients ages 18-59, Ambulatory only. The Licensee has submitted a request for a capacity increase from forty six (46) clients ages 18-59 to forty eight (48) clients ages 18-59, Ambulatory only. A fire clearance increase was granted by Inspector Jim Groff. The capacity increase is currently pending through CCL. During today's visit, LPA used the infection control domain to complete the Required - 1 Year inspection. Also, the physical plant was toured, medications and food supplies reviewed.

The facility is operating within the scope of it's license. The facility consists of 6 separate buildings.
Building 1 includes a living room, dining room, office, kitchen, six bedrooms (shared) and two bathrooms.
Building 2 includes 2 bedrooms (shared) and 2 bathrooms. There is one vacancy in room #4.
Building 3 includes 1 bedroom (shared), 1 bathroom, laundry room and storage room.
Building 4 includes 2 bedrooms and 1 bathroom.
Building 5/Office includes 10 bedrooms (shared) and 5 bathrooms. There is one vacancy in room #12.
Building 6/Trailer includes 3 bedrooms, 2 bathrooms, a living room/lounge and a kitchen (without a stove). No cooking is done in the trailer.

LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. LPA toured a random selection of client rooms. Client rooms were furnished appropriately. The bathrooms were observed to be clean and operational. The hot water temperature was tested throughout the facility. The outdoor patio area was enclosed. There is no pool or other large bodies of water. The back yard is free of debris /hazards and outdoor passageways are free of obstruction. The trash cans have covered lids.
(Please see LIC 809C for additional information)
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE: DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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: C.M.A.
FACILITY NUMBER: 191591729
VISIT DATE: 09/02/2021
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Facility has a working landline. The kitchen was observed for the ability to prepare and serve food. There was a sufficient amount of perishable/non-perishable and emergency food supplies. No pesticides or poisons were stored in the food areas. Medications/Medication Administration Records were reviewed. Medications are centrally stored and locked in building 5/office. Knives, disinfectants, and cleaning solutions are kept locked and inaccessible to clients. All required information (COVID-19, Emergency Exiting Floor Plan, Personal Rights, Ombudsman information, Theft and loss policy and Emergency Telephone Numbers) are posted inside the facility. The fire extinguishers are fully charged and meet Title 22 Regulations.
Smoke detectors, carbon monoxide detectors and signal system are operational.

The following deficiency was observed during today's visit and must be corrected prior to approval of the capacity increase.;
  • At 11:13AM, the hot water temperature was tested in bathroom located in building 2 and measured at 120.9 degrees F.
  • At 11:47AM, the hot water temperature was tested in shared bathroom located in building 5/office and measured at 104.9 degrees F.



During today's visit, LPA requested a current facility sketch for each building (total 6), showing the number of rooms / beds / bathrooms. Capacity increase is pending submission and approval of facility sketch.

The following deficiency was observed to be in violation of California code of Regulations, Title 22, Division 6 (refer to 809D)
An exit interview was conducted and a copy of this report was provided to the Administrator along with the Appeals Rights.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/08/2021 08:52 AM - It Cannot Be Edited


Created By: Joe Katrdzhyan On 09/02/2021 at 02:32 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: C.M.A.
FACILITY NUMBER: 191591729

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
8088(e)(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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At 11:13AM, the hot water temperature was tested in bathroom located in building 2 and measured at 120.9
degrees F. At 11:47AM, the hot water temperature was tested in shared bathroom located in building 5/office and measured at 104.9 degrees F. This poses an immediate health, safety risk to persons in care.
POC Due Date: 09/03/2021
Plan of Correction
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Administrator will ensure that the hot water temperature is maintained between 105 degrees F - 120 degrees F throughout the facility as required and submit a log for the next 24 hours showing the actual reading in buildings 2 and 5.
POC must be submitted to CCL by the POC due date.
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 Ho
LICENSING EVALUATOR NAME:Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:
DATE: 09/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2021


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