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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191591729
Report Date: 09/01/2022
Date Signed: 09/02/2022 04:33:00 PM


Document Has Been Signed on 09/02/2022 04:33 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: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:48CENSUS: 47DATE:
09/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:17 AM
MET WITH:Facility Manager, Jonathan AmarasingheTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced site visit for the Required - 1 Year inspection, focusing on the Infection Control Practice domain. Upon arriving at the facility, LPA met with Activity Staff Anuradha Karunaratne and Direct Care Staff Muditha Edirisuriya. At 9:25 am, LPA Pena spoke with the Administrator Manel Swarna Amarasinghe on the phone. She stated that she will not be able to come to the facility due to a recent death in the family. LPA was later joined by the Facility Manager Jonathan Amarasinghe who assisted with the visit. The purpose of the visit was explained. The facility is licensed to serve for a capacity of forty-eight (48) mentally disabled adults, clients ages 18-59, Ambulatory only, current census is 47 clients. 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. LPA requested and obtained a copy of the facility sketch for total of six (6) buildings showing the number of rooms / beds / bathrooms.

LPA Pena along with the Facility Manager toured the physical plant areas inside and outside to ensure there are no health and safety hazards. 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 areas have furniture and coverings. 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.

The following was observed/inspected:
  • The facility had a universal entrance screening area including a thermometer, PPE supplies, screening logs, and sign-in sheet.
  • COVID-19 signage was placed in only a few areas of the facility. Proper hand washing posters are not present in some bathrooms. Staff screened and took the temperature of LPA only when reminded by the LPA.
  • Two (2) of the staff on duty did not wear face masks.
  • Facility maintained a 30-day supply of PPE located in the locked supply closet in the laundry room. Additional masks were purchased and added to the stockpile during the visit.
  • The facility consists of 6 separate buildings.
  • Building 1 includes a living room, dining room, office, main kitchen equipped with appliances and equipment. There are six (6) bedrooms (shared), two (2) bathrooms and office. There are 12 clients living in this building.
  • Building 2 includes 2 bedrooms (shared) and 1 bathroom. There are 4 clients living in this building.
  • Building 3 includes 2 bedrooms (shared), 2 bathrooms. There are 4 clients living in this building.
  • Building 4 includes 1 bedroom and 1 bathroom. Right next to this bldg. is a laundry room and a storage room. There are 2 clients living in this building.
  • Building 5/Office includes 10 bedrooms (shared) and 5 bathrooms. There is one vacancy in room #15. There are 19 clients living in this building.
  • 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. There are 6 clients living in this building.


Continued on LIC809-C.....
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022
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: 09/01/2022
NARRATIVE
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  • There are 5 shaded patio areas with six (6) umbrellas, tables and chairs for clients' use.
  • Water temperatures were measured in the kitchen and random bathrooms. Some of the hot water readings were not within the required 105 - 120 degrees. Reading as follows:

    • Bathroom #1 in Bldg. 2 read 126.3 deg. F
    • Bathroom #1 in Bldg. 3 read 127.4 deg. F
    • Bathroom #2 in Bldg. 5 read 96.7 deg. F
    • Bathroom #1 in Bldg. 6/Trailer read 99.1 deg. F
  • The laundry room is clean and has cleaning supplies inaccessible to residents.
  • The kitchen was observed for the ability to prepare and serve food. There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. All the appliances are cleaning and are working properly. Knives and sharp items are locked in a kitchen cabinet.
  • Medications were locked, centrally stored, and given as prescribed. Medications were reviewed for some clients and facility maintained a 30-day supply of medications. 5 clients' medications were reviewed to confirm medication is given as prescribed and is documented properly.
  • Five (5) of the Staff who dispense medications did not have proper medication training.
  • Bathrooms have non-skid materials and contained hygiene supplies including liquid soap, paper towels, and toilet paper.
  • Smoke detectors/carbon monoxide detectors were present in different buildings and LPA observed that some of these detectors are inoperable..
  • Administrator Manel Swarna Amarasinghe' s certificate expires 3/24/2024.
  • Sufficient food supply of 2-day perishable and 7-day nonperishable were observed.
  • The two (2) fire extinguishers were last inspected on 2/03/2022. One (1) fire extinguisher was located in the main kitchen, and the other one (1) was in the kitchen in the Bldg. 6/Trailer.
  • Facility has two (2) working telephone landline.

Continued on LIC809-C......
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/02/2022 04:33 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
80087 Buildings 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: Broken or missing covers of the ceiling light fixtures in some of the clients' rooms.
Deficient Practice Statement
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Based on LPA's observations, the licensee did not comply with the section cited above in that the cover for the ceiling light fixtures in some of the clients rooms are broken or missing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2022
Plan of Correction
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The Facility Manager or Administrator will send photos of the fixed ceiling lighting covers in the clients rooms and bathrooms by email to LPA by 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: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/02/2022 04:33 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in that the smoke detectors and carbon monixide detectors in some of the clients bedrooms were inoperablewhich poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/02/2022
Plan of Correction
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Administrator or Facility Manager will submit pictures of the fixed/or new smoke and carbon monoxide detectors in clients bedrooms to CCLD within 24 hours. POC due date is 9/02/2022.
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: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022
LIC809 (FAS) - (06/04)
Page: 5 of 9


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: 09/01/2022
NARRATIVE
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The following deficiencies were observed to be in violation of California code of Regulations, Title 22, Division 6 and HSC codes (refer to 809D)
  • At 10:53AM, the hot water temperature was tested in shared Bathroom #1 located in Bldg. 2 and measured at 126.3 deg. F
  • At 11:07AM the hot water temperature was tested in shared Bathroom #1 in Bldg. 3 and read at 127.4 deg. F
  • At 11:26AM the hot water temperature was tested in shared Bathroom #1 in Bldg. 5 and read at 96.7 deg. F
  • At 11:39AM the hot water temperature was tested in shared Bathroom #1 in Bldg. 6/Trailer and read at 99.1 deg. F
  • Medication Training for Five (5) Staff who dispense medicines.
  • Broken ceiling light covers.
  • Broken smoke detectors in some of the clients' rooms and the living room area in Bldg. 6/Trailer.

An exit interview was conducted and a copy of this report was provided to the Facility Manager, Jonathan Amarasinghe along with the Appeals Rights.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022
LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 09/02/2022 04:33 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
80088 Furniture, Fixtures, 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: 2 shared bathrooms hot water read 96.7 deg F and 99.1 deg F. And 2 shared bathrooms hot water read 126.3 and 127.4
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 4 of the shared bathrooms hot water temperature read outside the required 105-120 deg F. temperature which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2022
Plan of Correction
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Administrator and or Facility Manager 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, 3, 5 and 6.
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: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022
LIC809 (FAS) - (06/04)
Page: 9 of 9


Document Has Been Signed on 09/02/2022 04:33 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(1)

(1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 16 hours of initial training. This training shall consist of eight hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and eight hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in that Five (5) Staff who administered medications to clients have experience ranging between 2-20 years but did not have the required medication training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2022
Plan of Correction
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Submit medication training certificates for all five (5) Staff to CCLD by POC due date.
Type B
Section Cited
CCR
80075(b)(A)(B)
AMENDMENT TO PREVIOUS CITATION SECTION CITED HSC 1569.69(1)
CORRECT CITATION: 80075 Health Related Services

(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

(A) In ARFs, facility staff must receive training from a licensed professional.

1. The licensee shall obtain written documentation from the licensed professional outlining the procedures and the names of facility staff who have been trained in those procedures.

2. The licensee ensures that the licensed professional reviews staff performance as the licensed professional deems necessary, but at least once a year.

(B) All staff training shall be documented in the facility personnel files.

This requirement is not met as evidenced by:


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interviews and record reviews, the licensee did not comply with the section cited above as Five (5) Staff who administer medications did not receive professional training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2022
Plan of Correction
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Facility Manager/Administrator will make sure that all five (5) staff are trained professionally and submit the medication training certificates to CCLD by POC due 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: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022
LIC809 (FAS) - (06/04)
Page: 3 of 9