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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191601199
Report Date: 06/06/2022
Date Signed: 06/06/2022 06:52:24 PM

Document Has Been Signed on 06/06/2022 06:52 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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:DIANA-RENE FAMILY CAREFACILITY NUMBER:
191601199
ADMINISTRATOR:RENTERIA, DIANA L.FACILITY TYPE:
735
ADDRESS:24231 AMBASSADOR PLACETELEPHONE:
(310) 539-3345
CITY:HARBOR CITYSTATE: CAZIP CODE:
90710
CAPACITY: 6CENSUS: 4DATE:
06/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:56 PM
MET WITH:Administrator - Eve TigheTIME COMPLETED:
03:15 PM
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On 06/06/2022, Licensing Program Analyst (LPA) Don Senaha conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with Administrator Eve Tighe and explained the purpose of today’s visit. The facility is licensed to operate for six (6) developmentally disabled adults between the ages of 18 through 59.

The facility is single story structure located in a residential neighborhood. It consists of the following: three (3) client rooms, two (2) client bathrooms, one staff room used for office space as well, one (1) living area, one (1) dining area, kitchen, and outside patio area with a table and umbrella for shade.

LPA and Administrator toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured between 105.0 F to 106.7 F in the bathrooms and kitchen sink. The laundry area is located next to the kitchen. A comfortable temperature of 74 degrees was maintained in the facility.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies and toxins were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. The grocery shopping takes place every three to four days. There are two (2) fire extinguishers fully charge, one (1) in the kitchen and one (1) at the end of the hallway, smoke detectors and carbon monoxide were operable. A reviewed of Medication Records Administration (MAR) and observed to be maintained in order and accurate.

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2022
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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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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: DIANA-RENE FAMILY CARE
FACILITY NUMBER: 191601199
VISIT DATE: 06/06/2022
NARRATIVE
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During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

There was one deficiency cited during this inspection visit (see LIC 809D).

Advisory Notes – One (1) Technical Assistance was issued, please see LIC9102-AN.

An exit interview was conducted and a copy of this report was provided to Administrator Eve Tighe.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/06/2022 06:52 PM - It Cannot Be Edited


Created By: Don Senaha On 06/06/2022 at 02:20 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: DIANA-RENE FAMILY CARE
FACILITY NUMBER: 191601199

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. There was a knife and scissors located in an unlocked drawer in the kitchen which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/07/2022
Plan of Correction
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Licensee immediately removed the sharps and moved them to a locked cabinet in the kitchen. Licensee to in-service training with each staff to remind them to all sharps must be locked at all times.
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Don Senaha
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2022


LIC809 (FAS) - (06/04)
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