197606656-9-21-2023-28-AS-CWOG-CVNQUG-20230914122842

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606656
Report Date: 09/14/2023
Date Signed: 09/21/2023 08:45:56 AM

Document Has Been Signed on 09/21/2023 08:45 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
GREATER LA AC/SC, 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:	09/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Nicholas Baez		TIME COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Christine Wong conducted an unannounced annual required inspection and met with caregiver Lorenzo Tii who allowed the entry of the facility and explained the reason of the visit. Shortly after, the house manager Nicholas Baez arrived and assisted with the visit. 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 twelve (12) tool domains were observed and reviewed: Infection Control, Operational Requirements, Physical Plant/Environmental Safety, Staffing, Personal Records-Training, Resident Rights/Information, Resident Records/Incident Reports, Planned Activities, Food Service, Incidental Medical and Dental, Disaster Preparedness and Resident with Special Health Needs. 1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is still in place. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. 2. Operational Requirements: A fire clearance for four (4) ambulatory and two (2) non-ambulatory and currently three (3) residents are ambulatory and one (1) resident is non-ambulatory. The facility is vendored by San Gabriel Pomona Regional Center, therefore no dementia waiver and hospice waiver in place at the present time. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place. A Surety Bond is in place. The facility handles resident monies. 3. Physical Plant and Environmental 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. Exit doors are free of any obstruction and there are no pools or large bodies of water. (See Next Page)

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

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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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: KATIE'S HOUSE	FACILITY NUMBER: 197606656
	VISIT DATE: 09/14/2023

NARRATIVE

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Bedroom#1 has two beds, two drawers, required furniture and bedding and sufficient lighting and closet space. Bedroom#2, #3 and #4 has one bed, one drawer, one chair, night stand, required bedding and furniture and sufficient lighting and closet space. The two clients' bathrooms are clean and sanitary. The water in the Bathroom#1 sink was not drained. The bathrooms also have the required grab bar and non-skid mat, The hot water in both bathrooms were tested between 110.4 and 111.2 degrees F. which are within the Title 22 regulation. All the sharp knives and utensils are stored and locked in the medication cabinet near the living room. All the appliances in the kitchen and living room are working probably. All the chemicals and cleaning supplies are stored and locked in the cabinet in the garage. LPA also inspected the smoke detectors and they are all interconnected and also inspected the carbon monoxide detectors and its working well. The facility has a land-line telephone system for residents to access.

4. Staffing: The facility has sufficient staffing in the facility. Also all staff has an updated CPR and First Aid Training. The night shift staff also has an planned emergency procedure training.

5. Personnel Records-Training: The staff files are stored in the medication cabinet. All staff are over 18 years old and criminal background clearance and associated with the facility. The administrator is Carrie Dobrenen and her certificate is expired on 11/15/23. The administrator has all the required training. All the staff also has completed the 10 hours of initial training and ongoing training each year.

6. Resident Records-Incident Reports: The residents files are stored in the medication cabinet. LPA inspected four (4) resident files: Each resident files has the required documents including face sheet, admission agreement, updated physician report and updated Individual Program Plan (IPP) but 3 of the residents have no preplacement appraisal information in resident's files.

7. Resident-Right Information: RCFE complaint poster (Long Term Care Ombudsman and Community Care Licensing) and Personal rights were observed posted but no nondiscrimation notice. The Incident report folder was reviewed.

8. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Also the facility has different recreational materials for residents to utilize.

(See Next Page)

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KATIE'S HOUSE	FACILITY NUMBER: 197606656
	VISIT DATE: 09/14/2023

NARRATIVE

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9. Food Service: The facility has sufficient supply of 2 days non-perishable and 7 days non-perishable food supply and emergency food supplies. All the food are stored probably in the facility. No residents in the facility are currently on modified diet but facility staff will chop the food into small pieces to prevent choking.

10. Incidental Medical and Dental: Facility will provide transportation for residents' medical and dental appointment. All the medication in the facility are centrally stored and locked in the medication cabinet. LPA inspected four (4) residents' medication and all residents' medication are seemed accurate and updated. And all resident receive 30 days supply of medication.

11.Disaster Preparedness: The updated emergency disaster plan was updated (LIC610E) and the last emergency drill was conducted on 8/21/23. The facility also has two alternative temporary shelter location. Records of resident Appraisal and Needs services plans are part of Emergency training.

12.Residents with Special Health Needs: Currently no residents are on hospice or home health, also no residents with restricted health condition or prohibited health condition or postural support.

Per California Code of Regulations, Title 22, deficiencies were cited.

Exit interview was conducted with Nelida Arlante. A copy of the report and appeal rights were issued.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/21/2023 08:45 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
GREATER LA AC/SC, 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: 09/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(6)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation, LPA observed the water in the bathroom#1 sink was not able to drain which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/28/2023
	Plan of Correction
1 2 3 4	The administrator will ensure the facility shall be maintained in operating condition. The facility will contact the plumber and fix the driainng issues problem and send the picture to LPA by 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: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

LIC809 (FAS) - (06/04)

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