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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191800993
Report Date: 06/19/2023
Date Signed: 06/19/2023 04:18:05 PM

Document Has Been Signed on 06/19/2023 04:18 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:WILTON HAVENFACILITY NUMBER:
191800993
ADMINISTRATOR:BARRIOS, MARIAFACILITY TYPE:
735
ADDRESS:909 S. WILTONPL.TELEPHONE:
(323) 737-1844
CITY:LOS ANGELESSTATE: CAZIP CODE:
90019
CAPACITY: 30CENSUS: 28DATE:
06/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Marc DayaoTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced visit at the facility for the purpose of conducting the required annual inspection. LPA utilized the Compliance and Regulatory Enforcement (CARE) Tool to evaluate the facility. LPA Gonzalez met with Administrator Marc Dayao and explained the purpose for the visit.

The facility is licensed to serve (30) developmentally disabled adults ages 18-59 years old, all Ambulatory. Currently, there are (28) clients in placement, there are no clients who have a restricted health care condition.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical Services, Disaster Preparedness, and Emergency Intervention.

During the visit LPA observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has sufficient PPE supplies, has an Infection Control Plan and Mitigation Plan. Facility has COVID-19 signage posted throughout the facility. Bathrooms have hand washing signs, soap and paper towels. Per Facility Administrator all facility clients have COVID-19 vaccines including boosters. Per Facility Administrator all staff also have the COVID-19 vaccines including boosters. Facility Administrator is adhering to infection control requirements.


Refer to LIC 809C for continuation of report
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: WILTON HAVEN
FACILITY NUMBER: 191800993
VISIT DATE: 06/19/2023
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Operational Requirements: Fire Drills are conducted monthly, the last fire drill was conducted on 3/13/23. Emergency Disaster/ Earthquake Drills are also conducted monthly and the last one was conducted on 3/13/23. Facility Administrator is adhering to operational requirements.

Physical Plant & Environment Safety: The home is consists of a 2 story building located in a residential area and contains the following: 11 client bedrooms downstairs and 10 upstairs, 6 bathrooms, dining room, kitchen and laundry room. Facility has a shaded front porch and a back yard with sufficient seating. The front, back and side areas of the house are free of hazards and/ or obstructions. Backyard has a shaded area and seating for client use. Facility has a room with a washer and dryer. All common areas were properly furnished and appeared comfortable. All client rooms that were inspected had the required furniture for comfort and safety and had sufficient lighting. All bathrooms were observed to be clean and had the required hygiene items. Bathrooms all have a supply of hand soap and paper towels. Linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents. The hot water temperature measured between 113-117 F which is within the required 105 - 120 degrees. There is sufficient lighting throughout the facility. The grounds are well groomed. Cleaning supplies are kept locked and inaccessible to clients. Trash containers have covered lids. There are no security bars nor weapons on the premises. Facility temperature was comfortable. First aid kit is fully stocked with manual, smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to clients. Hazardous toxins and/or items are inaccessible to clients, fire extinguisher(s) are fully charged. Exits were marked with signs. Notifications and postings were observed which included personal rights, facility sketch, visitor policy, complaint procedures, menu and emergency disaster plan.

Staffing: There is sufficient staffing at the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator, and S1-3. Staff have current CPR/first aid training and sufficient on-going training that meets the annual requirement. Staff have their Health Screening and Tuberculosis Screening on file.

Refer to LIC 809C for continuation of report
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: WILTON HAVEN
FACILITY NUMBER: 191800993
VISIT DATE: 06/19/2023
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Client Rights-Information: Client personal rights and House Rules are posted. Per Facility Administrator, facility provides wi-fi services to all clients which clients utilize through their personal cell phone.

Client Records-Incident Reports: LPA reviewed Client files for C1 through C3. Client files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment, Appraisal Needs and Services Plan, Functional Capabilities Assessment, Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights.

Food Service: The facility has sufficient food supplies of 2-day perishable and 7 day supply of non-perishable items. The food is properly stored in the refrigerator which is clean and well-maintained. There are no clients with special diets residing at this facility. Kitchen is kept clean and free from rodents and other bugs/ insects. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services: The medications are centrally stored and in their original containers. LPA reviewed medication for C1 through C3. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubble packed and delivered monthly.

Incidental Medical Services: Per Facility Administrator, there are no clients at this home with incidental medical services nor any client that has a restricted health condition.

Disaster Preparedness: The facility has an Emergency Disaster Plan readily accessible.

Emergency Intervention : Not-Applicable.


No deficiencies noted. Exit interview and a copy of this report was provided to Administrator Marc Dayao.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023
LIC809 (FAS) - (06/04)
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