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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603739
Report Date: 12/06/2024
Date Signed: 12/06/2024 01:14:10 PM

Document Has Been Signed on 12/06/2024 01:14 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:MENTONE HOUSEFACILITY NUMBER:
197603739
ADMINISTRATOR/
DIRECTOR:		ROBIN PHILLIPSFACILITY TYPE:
735
ADDRESS:1980 MENTONETELEPHONE:
(626) 398-5629
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 6CENSUS: 5DATE:
12/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Magdalena Estrada - Administrator
Luis Whitlock - DSP I & II		TIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required-1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA arrived at the facility and rang the doorbell but no one answered. LPA called the Administrator, Magdalena Estrada who said she will come over in a few minutes. At 10:05am, LPA met with the Administrator and Luis Whitlock, DSP I & II and explained the purpose of today's visit. The facility is approved to serve developmentally disabled clients ages 18 through 59 years, ambulatory only. Services provided by Frank D. Lanterman Regional Center. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained. Staff are adhering to infection control requirements. The facility has submitted a COVID-19 Mitigation Plan and the Infection Control Plan. The Infection Control Plan has not been updated nor included in the Plan of Operation.
Physical Plant & Environment Safety: This facility is a single story home consists of kitchen, dining room, living room, (4) client bedrooms, (2) bathrooms, den/activity area, laundry area, detached garage and a backyard. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, chair and sufficient closet space. Smoke alarms and carbon monoxide were tested and operable. Laundry area is next to the kitchen. The fire extinguisher in the kitchen was recently inspected on 11/01/2024. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. There are no firearms or weapons stored at the facility. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Exit doors are free of any obstruction and there are no pools or large bodies of water. Backyard was inspected and has a shaded area and sitting area. LPA observed an old large sofa left next to the detached garage waiting to be picked up for trash. There is no camera in the facility.
Operational Requirements: A current Plan of Operation was reviewed. A fire clearance is in place. Surety Bond in the amount of $12,000 is valid and expires on 02/08/2026. Last Fire Drill was conducted on 12/06/2024.
*****Refer to LIC 809C for the continuation of this report.*****
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2024
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 5
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: MENTONE HOUSE
FACILITY NUMBER: 197603739
VISIT DATE: 12/06/2024
NARRATIVE
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Staffing: A total of nine (9) staff members including the Administrator provide care and supervision to the client. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility.
Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed (5) staff files including the Administrator. Proof of staff training, health clearance, and vaccinations are current. Administrator certificate is valid and expires on 03/28/2025. Administrator has a valid HIV/AIDS training.
Client Rights-Information: Client personal rights are posted. Facility provides internet service and phone to the client.
Client Records-Incident Reports: LPA reviewed (5) client files. Client file is maintained at the facility. Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Special Incident Reports, Client Personal Property and Clients Personal Rights observed.
Food Service: There is sufficient food supplies of 2-day perishable and 7-day supplies of non-perishable items. The food is properly stored in the refrigerator. There are no clients with special diets residing at this facility. Pesticides and cleaning supplies are kept away from the food preparation areas.
Health Related Services: The medications are centrally stored and in their original containers. LPA reviewed medication for C1-C5. The facility uses the Medication Administration Record (MAR) log to document medications given. LPA observed that 2 of C5's medications were administered fro 12/01/2024-12/06/2024, but medications were not listed and not properly documented/initialed by staff on medication administration record (MAR). Medications are administered as prescribed by the Physician.
Incidental Medical Services: Per Administrator, there is one (1) client at this home with a restricted health condition.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan.
Emergency Intervention: Not-Applicable.

Deficiencies cited on LIC 809D. Exit interview, appeals rights and a copy of this report was provided to Administrator, Magdalena Estrada.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 12/06/2024 01:14 PM - It Cannot Be Edited


Created By: Bennette Pena On 12/06/2024 at 12:12 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MENTONE HOUSE
FACILITY NUMBER: 197603739

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(C)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (C) A record of each dose is maintained in the client's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the client's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the Administrator did not comply with the section cited above in that LPA observed that 2 (multivitamin tablet and levothyroxine 50 mcg tablet) of C5's medications were administered from 12/01/2024-12/06/2024, but medications were not listed and not properly documented/initialed by staff on medication administration record (MAR). which poses an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 12/09/2024
Plan of Correction
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Administrator will ensure to check the medications and the list when received from the pharmacy. Administrator to ensure to get proper medication training for the staff and obtain correct Medication Administration Record for all the clients. Administrator will submit a copy of the medication training for staff and updated MAR for C5 on or before the POC due 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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 12/06/2024 01:14 PM - It Cannot Be Edited


Created By: Bennette Pena On 12/06/2024 at 12:12 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MENTONE HOUSE
FACILITY NUMBER: 197603739

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2024

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 Administrator did not comply with the section cited above in that Infection Control Plan has not been updated nor included in the Plan of Operation which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 12/13/2024
Plan of Correction
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Administrator will submit the updated Infection Control Plan and Plan of Operation to CCL/LPA by POC due date.
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, interview, the Administrator did not comply with the section cited above in that LPA observed that all the bedrooms' window frames and sills paints are peeling/chipping. And there is a huge gap in the upper area of the cabinets in the laundry area needed to be filled or fixed which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 12/13/2024
Plan of Correction
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Administrator will have a handyman fix the window frames/sills and the upper area of the cabinets and send proof/photos that these have been repaired to CCL/LPA 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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 12/06/2024 01:14 PM - It Cannot Be Edited


Created By: Bennette Pena On 12/06/2024 at 12:12 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MENTONE HOUSE
FACILITY NUMBER: 197603739

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the Administrator did not comply with the section cited above in that LPA observed an old large sofa left next to the detached garage which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 12/13/2024
Plan of Correction
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Administrator will schedule a trash pick up for the old large sofa and send proof such as photos that the area has been cleared to CCL/LPA by POC due 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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2024


LIC809 (FAS) - (06/04)
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