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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191593069
Report Date: 04/10/2023
Date Signed: 04/10/2023 03:42:59 PM

Document Has Been Signed on 04/10/2023 03:42 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
GREATER LA AC/SC, 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:
04/10/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:56 PM
MET WITH:Della Higgins, AdministratorTIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to complete the annual inspection. LPA arrived unannounced and met with Administrator, Della Higgins. The purpose of the visit was explained. LPA conducted the initial inspection on 3/23/23. During the visit today, LPA utilized the CARE tools to complete the rest of the domains listed below:

Operational Requirements: The facility is licensed for (4) adults ages 18 - 59, of which 2 may be non-ambulatory in bedroom #1. There are currently 2 clients residing at the home and were placed by the San Gabriel/Pomona Regional Center. Staffing: There is sufficient staffing at the facility. Staff are fingerprint cleared and associated to the facility. Personnel Records-Training: Staff files are maintained at the facility. Administrator (Della Higgins) certificate expires on 06/08/2024. Staff have current CPR/first aid training and training hours that meet the annual requirement. LPA reviewed (2) personnel files and they all have required documentation. Client Rights - Information: Clients are provided with internet access devices for use. Client Records-Incident Reports: Resident files are maintained at the facility. LPA reviewed all (2) client files and they have the required documentation including current Individual Program Plan. There are no clients with a restricted health condition and are all ambulatory. Health-Related Services: The medications are centrally stored and locked. LPA reviewed medications for just one client who is currently take medication. They are being administered as prescribed by the physician. Incidental Medical & Dental: There are no clients who require health services or have a health condition that need to be monitored more carefully. Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Emergency Intervention: Both staff have current CPR/first aid certificates. The staff do not need to use manual restraint on the clients at this home.

There are no deficiencies issued today. An exit interview was held and a copy of this report was provided to the Administrator.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2023
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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