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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191591729
Report Date: 08/31/2024
Date Signed: 08/31/2024 12:56:13 PM

Document Has Been Signed on 08/31/2024 12:56 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:C.M.A.FACILITY NUMBER:
191591729
ADMINISTRATOR/
DIRECTOR:		AMARSINGHE, SWARNAFACILITY TYPE:
735
ADDRESS:18432 GRIDLEY RD.TELEPHONE:
(562) 860-2479
CITY:ARTESIASTATE: CAZIP CODE:
90701
CAPACITY: 48CENSUS: 48DATE:
08/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:25 AM
MET WITH:DSP Anuradha KarunaratnaTIME VISIT/
INSPECTION COMPLETED:
01:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met DSP worker Anuradha Karunaratna at approximately 8:20 AM and explained reason for visit. Administrator Swarna Amarsinghe and Jonathan Amarasinghe arrived shortly.

The facility is licensed to serve for a capacity of forty-eight (48) mentally disabled adults, clients ages 18-59, Ambulatory only.


The facility is operating within the scope of its 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.
Building 3 includes 1 bedroom (shared), 1 bathroom, laundry room and pantry room.
Building 4 includes 2 bedrooms and 1 bathroom.
Building 5/Medication room includes 10 bedrooms (shared) and 5 bathrooms.
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 follows Title 22 Regulations. LPA toured a random selection of client rooms.: Each client bedroom has the required furniture and bedding. There is extra clean linen and towels in building #3 in cabinet where laundry room is. Smoke detectors were observed in each room and throughout the facility and are properly operating the bathrooms were observed to be clean and operational. The hot water temperature was tested throughout the facility. Building 1 BR #2 water tested at 128.1 and building 2 BR #1 126.4 not in the required range of 105-120 degrees F deficiency cited. Building #1 ceiling in living room was observed to be in disrepair. There were fire extinguishers fully charged and up to date. The kitchen was toured and contained working appliances; refrigerator, stove, oven and contained dishware, cups, plates, utensils, pots, and pans with knives secured. The pantry was well stocked with canned goods, pasta, cereals, and the food supply contained a sufficient supply with a two day supply of perishables and a seven day supply of non-perishables. Cleaning supplies and toxic substances are inaccessible to clients in a locked storage in laundry room as well as within a locked cupboard in kitchen. 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.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2024
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 4
Document Has Been Signed on 08/31/2024 12:56 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 08/31/2024 at 12:38 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: 08/31/2024

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 two (2) clients bathrooms water measured at 128.1 and 126.4 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/01/2024
Plan of Correction
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Administrator adjusted water at time of visit and will test water for a week and send LPA water log 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:Tony Vasallo
LICENSING EVALUATOR NAME:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/31/2024 12:56 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 08/31/2024 at 12:38 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: 08/31/2024

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
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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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:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: C.M.A.
FACILITY NUMBER: 191591729
VISIT DATE: 08/31/2024
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Five (5) Staff files were reviewed and included Criminal clearance record, CPR/training, and health screening with TB. Administrator certificate 6014768735 expiration date 03/24/2026. Five (5) Client files were reviewed and included physicians report, TB clearance and appraisal needs and service plans. Fire/earthquake drill was conducted on 07/23/2024. Infectious control plan was reviewed. The medications are centrally stored and locked in a cabinet in building #5 Medication room. The facility uses the Medication Administration Record (MAR) log to document medications given. LPA reviewed medications for five (5) random clients, and they are being administered as prescribed by the physician.

Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided to Jonathan Amarasinghe.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4