191801447-3-27-2023-11-AS-FSHY-CQBUDK-20230327152939

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191801447
Report Date: 03/27/2023
Date Signed: 03/27/2023 03:29:51 PM

Document Has Been Signed on 03/27/2023 03:29 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	ALPHA HOME FOR EXCEPTIONAL NEEDS		FACILITY NUMBER:	191801447
ADMINISTRATOR:	FELICIA FERNANDEZ		FACILITY TYPE:	735
ADDRESS:	3977 SO. DENKER STREET		TELEPHONE:	(323) 296-0228
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90062
CAPACITY: 6		CENSUS:	DATE:	03/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:53 AM
MET WITH:	Felicia Fernandez		TIME COMPLETED:	03:45 PM

NARRATIVE

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03/27/23, Licensing Program Analysts (LPA) Felisa Shirley conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA Felisa met with Administrator Felicia Fernandez. LPA Shirley explained the purpose of today’s visit. The facility is licensed to operate and care for six (6) developmentally disabled adults (ages 18 through 59 / ambulatory only). Currently, two (2) clients reside at this facility.

The facility is a two-story home located in a residential neighborhood. This facility contains, on the first floor: kitchen, dining room, living room, 4 bedrooms of which 2 are client bedrooms and two bathrooms. On the second floor: a master bedroom (for Administrator/Licensee) and bathroom with office area. Laundry area located in the garage and outside shaded area with table and chairs. Presently, two (2) clients have their own bedrooms. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided. Storage for client personal belongings was observed. LPA Shirley toured the physical plant. There were no bodies of water or obstructions on the premises. 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 113.8 degrees Fahrenheit. Storage areas for personal hygiene, medications, cleaning supplies, toxins, and sharp objects were stored, locked and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly. Smoke detectors and carbon monoxide detectors (hardwired with a battery backup) were operable.

Emergency numbers are posted and readily available for review. Facility has a land line telephone located in dining room and kitchen (323) 296-0228. Three fire extinguishers were fully charged.

Evaluation Report Continues on LIC 809-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023

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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Document Has Been Signed on 03/27/2023 03:29 PM - It Cannot Be Edited

Created By: Felisa Shirley On 03/27/2023 at 02:33 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: ALPHA HOME FOR EXCEPTIONAL NEEDS	FACILITY NUMBER: 191801447
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80019(e)(1)

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/28/2023
	Plan of Correction
1 2 3 4	Licensee stated that Bernice Braham-Huggins will immediately get LiveScan today and provide proof of correction by Plan of Correction due date 3/28/23 via fax.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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:

Stephanie Cifuentes

LICENSING EVALUATOR NAME:

Felisa Shirley

LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023

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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ALPHA HOME FOR EXCEPTIONAL NEEDS	FACILITY NUMBER: 191801447
	VISIT DATE: 03/27/2023

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During the visit, LPA Shirley observed the facility's infection control practices. LPA observed the facility has a 60-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has a Mitigation Plan Report approved by CCLD on file.

LPA Shirley noticed during record review that Staff Bernice Braham-Huggins is not listed on the LIC500 Staff Roster. Licensee provided copy of letter to Licensing requesting that Bernice Brayham-Huggins be added to roster but did not provide fingerprints.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

An Exit interview was conducted and Plans of Corrections were reviewed and developed with the Licensee. A copy of this report and appeals rights were discussed and left with the Licensee Felicia Fernandez, whose signatures on this form confirm receipt of these documents.

End of report

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023

LIC809 (FAS) - (06/04)

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