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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191840975
Report Date: 09/05/2024
Date Signed: 09/05/2024 12:34:16 PM

Document Has Been Signed on 09/05/2024 12:34 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:COMEAUX FAMILY HOMEFACILITY NUMBER:
191840975
ADMINISTRATOR/
DIRECTOR:		RUFFINS, PECOLAFACILITY TYPE:
735
ADDRESS:1470 W. ADAMS BLVD.TELEPHONE:
(323) 732-2424
CITY:LOS ANGELESSTATE: CAZIP CODE:
90007
CAPACITY: 15CENSUS: 7DATE:
09/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Stella Ruffins AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met with Administrator Stella Ruffins at approximately 9:00 AM and explained reason for visit.

Facility is licensed to serve up to (15) fifteen develop disabled clients ages 18 - 59 years old. The facility is a two-story building and consist of (5) client bedrooms & (2) two staff bedrooms, (3) storage rooms, (4) client bathrooms, (2) staff bathroom, living room, dining area, kitchen, indoor/outdoor activity areas, attic and basement, a back yard, and a front yard. There are no pools or large bodies of water.

LPAs conducted a tour of the facility with Stella Ruffins. LPA observed the following: Living room had paper and clutter on entertainment center and table area. There were soiled dog pads on floor, dining room has a day bed per Administrator is used as couch. Kitchen light was missing cover. Kitchen was observed and food supplies were observed for at least 2 days of perishables and 7 days of non-perishables. There is an extra freezer on patio with more food. Knives and sharps are locked in pantry cabinet and medication is locked in a cabinet across the refrigerator. During tour a box of cleaning supplies were observed to be left on floor in front of pantry accessible to clients. Each client bedroom has the required furniture and bedding. There is extra clean linen and towels in hallway closet. Smoke detectors were observed in each room and throughout the facility and are properly operating. LPA observed several fire extinguishers throughout the house. There are no firearms or weapons stored at the facility The hot water temperature in the bathrooms were not measured between the required range of 105-120 degrees F. The facility does not have a swimming pool or bodies of water on the premises There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction.

SEE LIC 809C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2024
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 6
Document Has Been Signed on 09/05/2024 12:34 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 09/05/2024 at 11:35 AM
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: COMEAUX FAMILY HOME
FACILITY NUMBER: 191840975

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2024

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, the licensee did not comply with the section cited above a box of cleaning supplies were left out in front of pantry door accessible to clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/06/2024
Plan of Correction
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Administrator locked cleaning solutions in pantry and will go over training and send training log to LPA.
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in three (3) out of four (4) bathrooms tested had a temperature over the 125 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/06/2024
Plan of Correction
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Bathroom # 2 127.4 on first floor.
Bathroom #1 125.2 and B2 127.3 on second floor.
Administrator will adjust water and send picture to LPA.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 09/05/2024 12:34 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 09/05/2024 at 11:35 AM
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: COMEAUX FAMILY HOME
FACILITY NUMBER: 191840975

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above did not have infection control plan at facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/19/2024
Plan of Correction
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Administrator will email LPA Infection Control Plan.
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above living room had clutter on entertainment center and table, soiled dog pad on floor and kitchen light was missing cover which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/19/2024
Plan of Correction
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Administrator will remove clutter,fix light fixcture and email pictures to LPA.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 09/05/2024 12:34 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 09/05/2024 at 11:35 AM
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: COMEAUX FAMILY HOME
FACILITY NUMBER: 191840975

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(k)
Administrator Qualifications and Duties
(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above Administrator did not have HIV/TB training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/19/2024
Plan of Correction
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Administrator will email LPA HIV/TB training by POC due date.
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above facility did not have a emergency disaster plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/19/2024
Plan of Correction
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Administrator will email LPA Emergency Diaster Plan by POC due date.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 09/05/2024 12:34 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 09/05/2024 at 11:35 AM
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: COMEAUX FAMILY HOME
FACILITY NUMBER: 191840975

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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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:Tony Vasallo
LICENSING EVALUATOR NAME:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: COMEAUX FAMILY HOME
FACILITY NUMBER: 191840975
VISIT DATE: 09/05/2024
NARRATIVE
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Five (5) staff files were reviewed and included Criminal clearance record, CPR/training, and health screening with TB. Administrator was missing HIV/TB training. Five (5) client files were reviewed and included physicians report, TB clearance, and individual program plan (IPP)report. Last fire/earthquake drill was conducted in December of 2023. Infectious control plan and disaster plan were inaccessible at time of visit deficiency cited. Four (4) client medications were reviewed. Medications are centrally stored and locked MAR log is used.

Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided to Stella Ruffins.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024
LIC809 (FAS) - (06/04)
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