191591749-7-8-2024-28-AS-TRES-D6SVHH-20240702162711

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191591749
Report Date: 07/02/2024
Date Signed: 07/08/2024 03:44:38 PM

Document Has Been Signed on 07/08/2024 03:44 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:	CASA DE ESPERANZA		FACILITY NUMBER:	191591749
ADMINISTRATOR:	DENISE WHITE		FACILITY TYPE:	735
ADDRESS:	12000 DENHOLM DR.		TELEPHONE:	(626) 444-8943
CITY:	EL MONTE	STATE: CA	ZIP CODE:	91733
CAPACITY:	15	CENSUS: 14	DATE:	07/02/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:39 AM
MET WITH:	Administrator Denise L. Hornal		TIME COMPLETED:	04:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Tyler Reyes conducted the required unannounced annual inspection. LPA met with Administrator Denise L. Hornal and explained the reason for the visit. Licensee prefers to serve Developmentally Disabled Adults ages 18-59 years. Fire cleared for 2 non-ambulatory and 13 ambulatory clients. Facility currently has (0) non-ambulatory and (14) ambulatory clients serviced by San Gabriel/Pomona Regional Center and Eastern Los Angeles Regional Center.

The facility is a single-story home located in a residential area in El Monte, CA. A tour of the facility includes: front yard, living room, dining room, TV room, kitchen, 8 client bedrooms, 4 client bathrooms, detached garage, and backyard.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following with Administrator Denise L.Hornal:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are cleaning and disinfecting throughout the day. Facility has an Infection Control Plan maintained at the facility.

Physical Plant & Environment Safety: LPA toured facility, clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. LPA Reyes observed with Administrator Hornal dog poop located on the side yard and backyard. Approximately 6 instances of dog poop were observed. The droppings were located along the side of the brick wall, by the shed, and the middle of the lawn. LPA observed two used cigarettes on an empty chair. LPA observed a desk, a dresser, and a bed frame situated on the back porch. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested in the client bathrooms and were within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked cabinet and are inaccessible to clients. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguishers was observed and is fully charged. Last Disaster Drill was completed December 21st, 2023, not within the required time frame. (Continued on 809-C)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Tyler Reyes	TELEPHONE: (323) 981-3306
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024

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 12

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: CASA DE ESPERANZA	FACILITY NUMBER: 191591749
	VISIT DATE: 07/02/2024

NARRATIVE

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Operational Requirements: Staff have proper training to meet the needs of the clients in care

Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the clients in the case of an emergency.

Personnel Records-Training: Staff files are maintained in a secure location within the facility. LPA reviewed 8 staff files during today’s visit. Upon record review LPA observed S1 missing a TB Test.

Client Rights-Information: Facility provides telephone landline for the clients. Client rights posters and reporting posters are displayed within the facility.

Client Records-Incident Reports: Client files are maintained in secured cabinet and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. LPA reviewed 8 client files with no issues.

Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.

Health Related Service: Staff designated to administer medication have the proper annual training on file. Medication is properly labeled and are centrally stored in a locked cabinet and are in their original containers. LPA reviewed 8 client’s medications during todays visit with no issues.

Incidental Medical & Dental: All training is documented in the facility personnel files. Staff performance is reviewed annually, and documentation is maintained in the personnel files.

Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Facility maintains documentation of the required emergency drills.

Deficiencies were cited per Title 22. Exit interview conducted, and a copy of the report/appeal rights were given to Administrator Denise L. Hornal

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Tyler Reyes	TELEPHONE: (323) 981-3306
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024

LIC809 (FAS) - (06/04)

Page: 2 of 12

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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CASA DE ESPERANZA	FACILITY NUMBER: 191591749
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

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 observations and interview, the licensee did not comply with the section cited above used cigarettes and dog poop was observed on the side yard and back yard which poses an immediate health risk to persons in care.
	POC Due Date: 07/02/2024
	Plan of Correction
1 2 3 4	Administrator Hornal will provide in-service training ensuring the outside yard is free from dog poop and used cigarettes. LPA Reyes observed Administrator Hornal disgard of the dog poop and cigarettes.

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: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Tyler Reyes	TELEPHONE: (323) 981-3306
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024

LIC809 (FAS) - (06/04)

Page: 3 of 12

Document Has Been Signed on 07/08/2024 03:44 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CASA DE ESPERANZA	FACILITY NUMBER: 191591749
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/02/2024

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
1 2 3 4	Based on observation and interview , the licensee did not comply with the section cited above furniture items a desk, dresser, and bed frame were in the passageways of the backyard which poses a potential health, safety risk to persons in care.
	POC Due Date: 07/05/2024
	Plan of Correction
1 2 3 4	Administrator Hornal will provide pictures showing the items of furniture from the backyard were removed to CCL by POC Due Date.

Type B

Section Cited

CCR

80077.3(a)(3)(C)

Care for Clients who Lack Hazard Awareness or Impluse Control

(C) Following the disaster and mass casualty plan specified in Section 80023, fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all facility staff who provide or supervise client care and supervision. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations and record review, the licensee did not comply with the section cited above the facility did not conduct a emergency disaster drill within the required time frame which poses a potential health safety risk to persons in care.
	POC Due Date: 07/09/2024
	Plan of Correction
1 2 3 4	Administrator Hornal will conduct an emergency disaster drill and provide documentation to CCL 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: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Tyler Reyes	TELEPHONE: (323) 981-3306
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024

LIC809 (FAS) - (06/04)

Page: 4 of 12

Document Has Been Signed on 07/08/2024 03:44 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CASA DE ESPERANZA	FACILITY NUMBER: 191591749
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80066(a)(11)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above S1 did not have a TB test which poses a potential health safety risk to persons in care.
	POC Due Date: 07/09/2024
	Plan of Correction
1 2 3 4	Adminstrator Hornal stated she will provide documnets of S1's TB Test to CCL by POC Due Date.

Type B

Section Cited

CCR

80075(g)

Health-Related Services

(g) If the facility has no medical unit on the grounds, first aid supplies shall be maintained and be readily available in a central location in the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations and interview, the licensee did not comply with the section cited above the facility does not have a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency which poses a potential health safety risk to persons in care.
	POC Due Date: 07/09/2024
	Plan of Correction
1 2 3 4	Administrator Hornal stated she will provide pictures and receipts of purchase of a First Aid manual to CCL 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: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Tyler Reyes	TELEPHONE: (323) 981-3306
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024

LIC809 (FAS) - (06/04)

Page: 5 of 12

Document Has Been Signed on 07/08/2024 03:44 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CASA DE ESPERANZA	FACILITY NUMBER: 191591749
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Deficiency Dismissed

Type A

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) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Tyler Reyes	TELEPHONE: (323) 981-3306
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024

LIC809 (FAS) - (06/04)

Page: 6 of 12

Document Has Been Signed on 07/08/2024 03:44 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CASA DE ESPERANZA	FACILITY NUMBER: 191591749
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Deficiency Dismissed

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
1 2 3 4	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
1 2 3 4

Deficiency Dismissed

Type B

Section Cited

CCR

80077.3(a)(3)(C)

Care for Clients who Lack Hazard Awareness or Impluse Control

(a) If a client requires protective supervision because of running/wandering away, supervision may be enhanced by fencing yards, using self-closing latches and gates, and installing operational bells, buzzers, or other auditory devices on exterior doors to alert staff when the door is opened. The fencing and devices must not substitute for appropriate staffing. (C) Following the disaster and mass casualty plan specified in Section 80023, fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all facility staff who provide or supervise client care and supervision. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	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
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: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Tyler Reyes	TELEPHONE: (323) 981-3306
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024

LIC809 (FAS) - (06/04)

Page: 7 of 12

Document Has Been Signed on 07/08/2024 03:44 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CASA DE ESPERANZA	FACILITY NUMBER: 191591749
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Deficiency Dismissed

Type B

Section Cited

CCR

80066(a)(11)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	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
1 2 3 4

Deficiency Dismissed

Type B

Section Cited

CCR

80075(g)

Health-Related Services

(g) If the facility has no medical unit on the grounds, first aid supplies shall be maintained and be readily available in a central location in the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	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
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: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Tyler Reyes	TELEPHONE: (323) 981-3306
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024

LIC809 (FAS) - (06/04)

Page: 8 of 12

Document Has Been Signed on 07/08/2024 03:44 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CASA DE ESPERANZA	FACILITY NUMBER: 191591749
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Deficiency Dismissed

Type A

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) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Tyler Reyes	TELEPHONE: (323) 981-3306
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024

LIC809 (FAS) - (06/04)

Page: 9 of 12

Document Has Been Signed on 07/08/2024 03:44 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CASA DE ESPERANZA	FACILITY NUMBER: 191591749
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Deficiency Dismissed

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
1 2 3 4	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
1 2 3 4

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: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Tyler Reyes	TELEPHONE: (323) 981-3306
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024

LIC809 (FAS) - (06/04)

Page: 10 of 12

Document Has Been Signed on 07/08/2024 03:44 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CASA DE ESPERANZA	FACILITY NUMBER: 191591749
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Deficiency Dismissed

Type B

Section Cited

CCR

80077.3(a)(3)(C)

Care for Clients who Lack Hazard Awareness or Impluse Control

(a) If a client requires protective supervision because of running/wandering away, supervision may be enhanced by fencing yards, using self-closing latches and gates, and installing operational bells, buzzers, or other auditory devices on exterior doors to alert staff when the door is opened. The fencing and devices must not substitute for appropriate staffing. (a) If a client requires protective supervision because of running/wandering away, supervision may be enhanced by fencing yards, using self-closing latches and gates, and installing operational bells, buzzers, or other auditory devices on exterior doors to alert staff when the door is opened. The fencing and devices must not substitute for appropriate staffing. (a) If a client requires protective supervision because of running/wandering away, supervision may be enhanced by fencing yards, using self-closing latches and gates, and installing operational bells, buzzers, or other auditory devices on exterior doors to alert staff when the door is opened. The fencing and devices must not substitute for appropriate staffing. (C) Following the disaster and mass casualty plan specified in Section 80023, fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all facility staff who provide or supervise client care and supervision. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	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
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: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Tyler Reyes	TELEPHONE: (323) 981-3306
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024

LIC809 (FAS) - (06/04)

Page: 11 of 12

Document Has Been Signed on 07/08/2024 03:44 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CASA DE ESPERANZA	FACILITY NUMBER: 191591749
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Deficiency Dismissed

Type B

Section Cited

CCR

80066(a)(11)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	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
1 2 3 4

Deficiency Dismissed

Type B

Section Cited

CCR

80075(g)

Health-Related Services

(g) If the facility has no medical unit on the grounds, first aid supplies shall be maintained and be readily available in a central location in the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	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
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: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Tyler Reyes	TELEPHONE: (323) 981-3306
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024

LIC809 (FAS) - (06/04)

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