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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191592733
Report Date: 09/07/2023
Date Signed: 09/07/2023 01:33:54 PM

Document Has Been Signed on 09/07/2023 01:33 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:L.A HOMEFACILITY NUMBER:
191592733
ADMINISTRATOR:SALVADOR, ERLINDAFACILITY TYPE:
735
ADDRESS:13881 SARANACTELEPHONE:
(562) 941-2830
CITY:WHITTIERSTATE: CAZIP CODE:
90604
CAPACITY: 6CENSUS: 4DATE:
09/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:14 AM
MET WITH:Mellanie Aikman, Staff TIME COMPLETED:
01:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to staff Kaylon De La Rosa. Administrator Designee Mellanie Aikman arrived shortly after. Administrator Erlinda Salvado was explained the purpose of the visit telephonically. There are four (4) ambulatory developmentally disabled adults ages 18-59. The facility is licensed as a level 3 home vendored by Eastern Los Angeles Regional Center. Twelve (12) Adult CARE tool domains were observed and reviewed.

Infection Control:

  • Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility encourages hand washing and self symptom check of staff and visitors. An Infection Control Plan has not been developed or submitted to CCL. Citation was issued.


Physical Plant/Environment Safety:
  • The facility is a single story home located in a residential neighborhood. It consists of 3 client bedrooms, 1 live-in staff room, 2 bathrooms, dining room, kitchen, living room, outdoor patio, and detached garage. Two (2) live-in staff (S2- S3) are residing in the staff room.

  • The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors were tested and are operational. The facility has tow (2) fully charged fire extinguishers.

  • A double sided lock on the metal gate door located on the right side yard that requires a key to unlock was observed.

  • R1's bedroom exit door to outdoor side yard has a nail installed that prevents the door from opening.

  • The stove's right side ignition knob is broken and shower tile/floor in small bathroom is dirty.

  • Water temperature readings measured between the required 105 - 120 degrees Fahrenheit.
See next page
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: L.A HOME
FACILITY NUMBER: 191592733
VISIT DATE: 09/07/2023
NARRATIVE
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Operational Requirements:
  • Fire clearance is approved for six (6) ambulatory residents only.
  • Care and supervision to meet the clients needs was observed. Special equipment and supplies are not used by clients.
  • Proof of surety bond policy was not provided.

Staffing:
  • A total of six (6) staff members provide care and supervision to the clients.

Personnel Records/Staff Training:
  • Administrator certificate expires 12/4/2024.
  • Four (4) staff files were reviewed. Criminal background clearance, personnel record, health screaning/TB clearance, training, and 1st Aid/CPR was on file.

Client Rights/Information:
  • Physician orders, and personal rights were reviewed in client files.

Client Records/Incident Reports:
  • Four (4) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, IPP reports, personal rights, medical consent, nutritional assessments, and medication administration records. Personal & Incidental (P & I) monies/records were reviewed.

Food Service:
  • The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.
  • There are no physician orders for modified diets.

See next page.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023
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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: L.A HOME
FACILITY NUMBER: 191592733
VISIT DATE: 09/07/2023
NARRATIVE
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Health Related Services:
  • Residents are assisted with self administration of prescription and non-prescription medications.
  • Centrally stored resident medication records were reviewed. They are kept in a safe and locked place not accessible to clients in care. Medications are given according to Physician directions. 30-Day supply of medications were observed.

Incident Medical and Dental:
  • All residents have a Needs and Services Plan, Physician Reports, and COVID-19 vaccination cards on file.

Disaster Preparedness, and Emergency Intervention:
  • A current Emergency Disaster Plan LIC 610D containing emergency evacuation information was not provided. Licensee is required to have an Emergency Disaster Plan/Disaster and Mass Casualty Plan. The plan shall be reviewed annually, updated as necessary, and maintained on file at the facility. Citation was issued.
  • First Aid Kit and Manual were observed.
  • The last emergency drill was conducted on 3/6/2021. It is not within the last 6 months. Citation was issued.


Emergency Intervention:
  • No manual restraints or seclusion are used with clients in care.

Per Title 22, California Code of Regulations, deficiencies were cited.


Exit interview conducted with staff Mellanie Aikman. A copy of the report and appeal rights were issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023
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Page: 3 of 7
Document Has Been Signed on 09/07/2023 01:33 PM - It Cannot Be Edited


Created By: Noemi Galarza On 09/07/2023 at 11:39 AM
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: L.A HOME
FACILITY NUMBER: 191592733

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80072(a)(7)
Personal Rights
Each client has the right not to be locked in any room, building, or facility premises by day or night.

This requirement was 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 in that LPA observed a double sided lock on the metal gate door located on the right side that requires a key to unlock, and R1's bedroom exit door to outdoors has a nail installed that prevents the door from opening; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/08/2023
Plan of Correction
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Licensee/Administrator agrees to:
1. Metal exit gate door's double sided lock is removed and/or replaced with a locking mechanism that allows staff and residents to exit the property without a key. Submit picture.
2. Screw from R1's bedroom door that leads to the side yard shall be removed. DSP staff removed the screw during the visit.
Submit picture proof evidence of the above by tomorrow.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023


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Document Has Been Signed on 09/07/2023 01:33 PM - It Cannot Be Edited


Created By: Noemi Galarza On 09/07/2023 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: L.A HOME
FACILITY NUMBER: 191592733

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80023(a)
Disaster & Mass Casualty Plan
(a) Each licensee shall have and maintain on file a current, written disaster and mass casualty plan of action.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that the facility does not have the current LIC 610D Emergency and Disaster Plan; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2023
Plan of Correction
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Administrator shall submit a copy of the updated LIC 610D Emergency and Disaster Plan. Facility shall post the plan.
Type B
Section Cited
CCR
80025(b)
Bonding
All licensees, other than governmental entities, who are entrusted to care for and control clients' cash resources shall file or have on file with the licensing agency, a bond issued by a surety company to the State of California as principal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that proof of Surety Bond was not provided; which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2023
Plan of Correction
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Administrator shall submit proof of active Surety Bond policy.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023


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Document Has Been Signed on 09/07/2023 01:33 PM - It Cannot Be Edited


Created By: Noemi Galarza On 09/07/2023 at 01:08 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: L.A HOME
FACILITY NUMBER: 191592733

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that an infection control plan was not submitted to CCL as required; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2023
Plan of Correction
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Administrator agreed to develop and submit a copy of the Infection Control Plan.
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, the licensee did not comply with the section cited above in that stove's right side ignition knob is broken and shower tile/floor in small bathroom is dirty, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2023
Plan of Correction
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Administrator agreed to submit proof of stove repairs and/or purchase, and picture of clean bathroom shower tile.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023


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Document Has Been Signed on 09/07/2023 01:33 PM - It Cannot Be Edited


Created By: Noemi Galarza On 09/07/2023 at 01:13 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: L.A HOME
FACILITY NUMBER: 191592733

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80023(d)
Disaster and Mass Casualty Plan.
Disaster drills shall be conducted at least every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that the last fire drill was conducted on 3/6/2021; which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2023
Plan of Correction
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Administrator agreed to submit a copy of the most recent Fire/Emergency drill log with staff signatures.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023


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