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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191592599
Report Date: 11/05/2021
Date Signed: 11/12/2021 10:34:13 AM

Document Has Been Signed on 11/12/2021 10:34 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:FOUNDERS HOUSE OF HOPEFACILITY NUMBER:
191592599
ADMINISTRATOR:CRYSEL SANTOSFACILITY TYPE:
735
ADDRESS:18025 PIONEER AVE.TELEPHONE:
(562) 860-3351
CITY:ARTESIASTATE: CAZIP CODE:
90701
CAPACITY: 98CENSUS: 82DATE:
11/05/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Dana OrdonezTIME COMPLETED:
04:45 PM
NARRATIVE
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On 11/5/2021, Licensing Program Analyst (LPA) Nina Galarza conducted an unannounced case management visit, the purpose of the visit is to follow up on deficiencies observed on 7/30/2021. LPA met with Assistant Administrator, Dana Ordonez and stated the purpose of the visit.

On 11/5/2021, LPA interviewed Assistant Administrator, Staff #1, and Clients 1-5 (C1-C5). On 11/5/2021, Assistant Administrator stated there are no bed bugs at the facility and no clients nor staff have reported bed bugs. During today's visit, LPA toured rooms 42,43,44,45 and 48. At 11:33 a.m. LPA observed dead bed bugs in room 44 on floor.

The following documents were obtained during today's visit:
  • a copy of Department of Public Health inspection report, dated September 2021
  • a copy of pest control treatment receipt and, dated September 2021

This is the third occurrence of repeated violations, under California Code of Regulations, Title 22, 80087, Buildings and Grounds.

Civil penalty in the amount $250 for repeat violation within 12 months was issued, refer to 809-D. Failure to correct deficiencies will result in additional civil penalties.

Exit interview was conducted, copy of report and appeal rights were provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nina Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2021
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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Document Has Been Signed on 11/12/2021 10:34 AM - It Cannot Be Edited


Created By: Nina Galarza On 11/05/2021 at 12:10 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: FOUNDERS HOUSE OF HOPE
FACILITY NUMBER: 191592599

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/12/2021
Section Cited
CCR
80087(a)(1)

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80087 Building 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. (1) The licensee shall take measures to keep the facility free of flies and other insects.
This requirement is not met as evidenced by:
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Facility will provide reciept of pest control treatment via email to LPA Nina Galarza by POC date
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Based on observation, the licensee did not comply with keeping facility free of bed bugs. LPA observed dead bed bugs in room 44. *Immediate civil penalties were assessed for a repeat violation for the amount of $250.*
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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:Nina Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 11/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2021


LIC809 (FAS) - (06/04)
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