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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603456
Report Date: 09/21/2023
Date Signed: 09/21/2023 05:38:22 PM

Document Has Been Signed on 09/21/2023 05:38 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
Lookup Error,
, CA
FACILITY NAME:ALICIA CARE CENTERFACILITY NUMBER:
197603456
ADMINISTRATOR:PEGGY PAYNE WALTERSFACILITY TYPE:
735
ADDRESS:1823 VASSAR AVE.TELEPHONE:
(818) 240-5171
CITY:GLENDALESTATE: CAZIP CODE:
91204
CAPACITY: 6CENSUS: 6DATE:
09/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:47 PM
MET WITH:Juan Alvarez, Administrator TIME COMPLETED:
05:44 PM
NARRATIVE
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Licensing Program Analyst ( LPA) Alberto Lopez made an unannounced annual inspection visit. LPA met with DSP Meleke Lewis and Administrator Juan Alvarez arrived a short time later and assisted with the visit. LPA explained the purpose of today's visit.

This is a one-story Adult Residential Facility (ARF) facility consisting of 4 client bedrooms, including 2 shared bedrooms and 2 bathrooms, kitchen, dining room, activities room, laundry room, medication closet, staff office located in detached garage and outdoor shaded area. This facility is licensed for a capacity of 6 clients and today's census was 6.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies. An Infection Control Plan was not posted at the facility but LPA observed the plan.


Physical Plant & Environment Safety: LPA observed 4 client bedrooms, 2 are shared and closet/drawer space to accommodate each client comfortably was available. There are 2 bathrooms at the facility, The facility is free of debris/hazards. There are no security bars or weapons on the premises. The hot water temperature was tested, and temperature measured between 120-125.6 degrees F which is not within required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are inaccessible to clients. The last Fire/Emergency Drill was 08/06/2023. Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguishers were observed and recently inspected.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2023
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 6
Document Has Been Signed on 09/21/2023 05:38 PM - It Cannot Be Edited


Created By: Alberto Lopez On 09/21/2023 at 05:20 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
,
, CA

FACILITY NAME: ALICIA CARE CENTER
FACILITY NUMBER: 197603456

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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. Water was tested at he facility and measured 120 - 126.6 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/22/2023
Plan of Correction
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Administrator will adjust water and send proof of correction to LPA by POC date.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/21/2023 05:38 PM - It Cannot Be Edited


Created By: Alberto Lopez On 09/21/2023 at 05:20 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
,
, CA

FACILITY NAME: ALICIA CARE CENTER
FACILITY NUMBER: 197603456

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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) (interview) (record review)], the licensee did not comply with the section cited above. Disinfectants, cleaning solutions were accessible to clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2023
Plan of Correction
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Staff locked up the Disinfectants, cleaning solutions during visit. ****No further action required****
Type B
Section Cited
CCR
85068.3(a)
Modifications to Needs and Services Plan
(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning.

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. 6 of 6 clients IPPis not updated which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
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Administrator will contact the Regional Center to obtain current IPP for all 6 residents and send proof 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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2023


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
Lookup Error,
, CA
FACILITY NAME: ALICIA CARE CENTER
FACILITY NUMBER: 197603456
VISIT DATE: 09/21/2023
NARRATIVE
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Operational Requirements: Facility is complying.

Staffing: There appears to be sufficient staffing in the facility. CPR/First aid certificates are on file. Administrator Juan Alvarez certificate expires on 06/08/2024.

Personnel Records-Training: Staff has criminal record clearance. Staff files are maintained at the facility located in online on facilities computer. Staff have current CPR/first aid training and documentation of ongoing training.


Client Rights-Information: Client personal rights poster is posted in the facility.
Client Records-Incident Reports: Client files are kept in a secure location within the facility office and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. IPP needs to be updated for all residents.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Service: Staff designated to administer medication do have the proper annual training on file. Medication is properly labeled and are centrally stored in a locked medication cabinet located in the kitchen. All medications are properly labeled and in their original containers. During the visit today, LPA reviewed all 5 clients' medications, all medication is administered according to doctor’s orders. One client does not take medications.
Incidental Medical & Dental: All medications for clients are kept locked and inaccessible to other clients.
Disaster Preparedness: The facility does not have an updated Emergency Disaster Plan posted at facility.
Emergency Intervention: Clients at this facility do not have restraints nor do they require the use de-escalation techniques.

Deficiencies cited during today's visit. Technical advisories also provided.

An exit interview was conducted and a copy of this report and appeal rights were provided to Administrator Juan Alvarez

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
LIC809 (FAS) - (06/04)
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