197606656-9-10-2024-28-AS-JVIS-D8YQ9A-20240910115802

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606656
Report Date: 09/10/2024
Date Signed: 09/10/2024 11:58:09 AM

Document Has Been Signed on 09/10/2024 11:58 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	KATIE'S HOUSE		FACILITY NUMBER:	197606656
ADMINISTRATOR:	CARRIE DOBRENEN		FACILITY TYPE:	740
ADDRESS:	15459 GARO STREET		TELEPHONE:	(626) 336-8273
CITY:	HACIENDA HEIGHTS	STATE: CA	ZIP CODE:	91745
CAPACITY:	6	CENSUS: 4	DATE:	09/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	House Manager Nick Baez		TIME COMPLETED:	12:10 PM

NARRATIVE

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Licensing Program Analyst(s) (LPA) Jose Villalobos and Luis De Leon conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with House Manager Nick Baez and the purpose of the visit was explained. The facility is licensed to serve adults age 60 and above. Fire clearance for four (4) ambulatory and two (2) non-ambulatory. The facility is licensed as a 4C home vendored by San Gabriel Pomona Regional Center.

The following CARE tools domains were utilized during the inspection.

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. Visitors are no longer screened for COVID-19 or required to sign in. The facility has an Infection Control Plan and COVID-19 Mitigation Plan.

Physical Plant/Environment Safety: The facility is a single story house and located in a residential neighborhood area. The facility includes: Living room, kitchen, dining area, four clients bedrooms, two clients bathrooms and attached garage. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Water temperatures measured within Title 22 requirements. The facility has one (1) fully charged fire extinguisher.

Operational Requirements: Facility has a fire clearance for four (4) ambulatory and two (2) non-ambulatory residents. Currently three (3) residents are ambulatory and one (1) resident is non-ambulatory. The facility is vendored by San Gabriel Pomona Regional Center. Facility was unable to provide LPA proof of required Liability Insurance. Facility has a surety bond in place.

Incident Medical and Dental: LPA reviewed medications for four (4) Residents. 30-day supply of resident medications were observed. The medications are centrally stored in locked cabinet. Centrally Stored Records for medications are kept. Medication stored matches the medication record for each resident.

Staffing: Sufficient caregiver staff provide care and supervision to the residents.

Continued on LIC 809-C

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

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 09/10/2024 11:58 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KATIE'S HOUSE	FACILITY NUMBER: 197606656
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.605

Other Provisions

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as facility was not able toprovide LPA with proof of liability insurance document during the visit which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/24/2024
	Plan of Correction
1 2 3 4	Facility to provide LPA a copy of the liability insurance via email or fax for the facility by the POC due date.

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: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KATIE'S HOUSE	FACILITY NUMBER: 197606656
	VISIT DATE: 09/10/2024

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Personnel Records/Staff Training: Administrator certificate is currently pending renewal from the department. Personnel files were reviewed. LPA reviewed a total of three (3) Staff files. LPA observed required documents for each. Proof of staff training was reviewed. 1st Aid/CPR records are current.

Resident Records/Incident Reports: A total of four (4) resident files were reviewed containing admission agreements, Physician's Reports, Appraisals, TB clearance, Functional Capability Assessment, and emergency information forms were observed. Appraisals on file are over a year old for each resident.

Residents Right-Information: RCFE complaint poster and Personal rights were observed to be posted.

Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Indoor and outdoor activities are performed. The facility does not have a Resident Council.

Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Cleaning supplies are locked separately from any food items.

Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place and was posted today. Facility to update to latest version of the form.

Residents with Special Health Needs: No residents receive home health services. No postural supports observed. (1) resident with half bed rails. No residents are on hospice. No residents have prohibited health conditions. No residents have restricted health conditions.

Per title 22 regulations, a deficiency is being cited on todays visit. Please see attached 809-D page. Exit Interview conducted. Appeal rights discussed. A copy of this report and the appeal rights were provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

LIC809 (FAS) - (06/04)

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