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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191593069
Report Date: 05/25/2022
Date Signed: 05/25/2022 02:56:54 PM

Document Has Been Signed on 05/25/2022 02:56 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:DELLA HIGGINS HOMEFACILITY NUMBER:
191593069
ADMINISTRATOR:HIGGINS, DELLAFACILITY TYPE:
735
ADDRESS:1105 OXFORD PLACETELEPHONE:
(909) 623-0555
CITY:POMONASTATE: CAZIP CODE:
91768
CAPACITY: 4CENSUS: 2DATE:
05/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Della Higgins, AdministratorTIME COMPLETED:
03:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vasallo conducted an annual required visit. LPA met with Administrator, Della Higgins and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the physical plant, COVID-19 procedures, reviewed clients' medications and records and observed the food supply, The facility cares for adults with intellectual disabilities and is vendorized by San Gabriel/Pomona Regional Center as a Level 4C facility.

Client bedrooms were toured. Each bedroom has a bed, linen, dresser, light, and sufficient closet space. Clients' bathroom was toured. Facility has a non-ambulatory fire clearance, however there were no grab bars near the toilet or in the shower as required for non-ambulatory clients. The hot water was 105.9 degrees which is within the required 105 - 120 degrees. There were no toxic chemicals accessible to clients. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and were operating properly at the time of the visit. The common areas include the living room and dining area. These areas are clean and have the required furniture. There is a screening station at the entrance of the home which has PPEs and a thermometer to screen visitors. Staff document client and staff temperatures daily. Facility currently has at least a 30-day supply of PPEs. There are cameras outside the facility, but none inside the facility.

Client files were reviewed to confirm emergency contacts are updated. Staff files were reviewed to confirm health screenings, training and fingerprint clearances. All clients' medications were reviewed. Medications are documented properly and given as prescribed.

Per California Code of Regulations, Title 22, the deficiency observed during the visit is documented on 809D. Exit interview held. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Tony Vasallo
LICENSING EVALUATOR SIGNATURE: DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/25/2022
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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Document Has Been Signed on 05/25/2022 02:56 PM - It Cannot Be Edited


Created By: Tony Vasallo On 05/25/2022 at 02:48 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: DELLA HIGGINS HOME
FACILITY NUMBER: 191593069

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations made, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. Facility has a non-ambulatory fire clearance and does not have grab bars near the toilet or in the shower.
POC Due Date: 06/08/2022
Plan of Correction
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Facility will submit proof of grab bars installed near the toilet and in the shower.
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:Wei Siew Ho
LICENSING EVALUATOR NAME:Tony Vasallo
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2022


LIC809 (FAS) - (06/04)
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