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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609591
Report Date: 02/10/2022
Date Signed: 02/10/2022 02:10:26 PM

Document Has Been Signed on 02/10/2022 02:10 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:T R E HOME IFACILITY NUMBER:
197609591
ADMINISTRATOR:JAMES CALHOUNFACILITY TYPE:
735
ADDRESS:1315 NORTON AVENUETELEPHONE:
(310) 863-4952
CITY:GLENDALESTATE: CAZIP CODE:
91202
CAPACITY: 5CENSUS: 4DATE:
02/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:42 AM
MET WITH:Keyrhon King, DSP and James Calhoun, Administrator TIME COMPLETED:
02:16 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Required- 1-year visit focusing on COVID-19 Infection Control Practices. LPA was greeted by DSP Kyerhon King and Administrator James Calhoun arrived around 60 minutes later and LPA explained the purpose of the visit. Administrator certificate expires 05/13/2022 Last fire drill was on 09/06/2021. Clients are from Lanterman Regional Center Home and is a level 4 specialize.
Structure:
Facility has a maximum capacity of five (5). A tour of the physical plant was conducted. The Facility consist of a single family, one (1) story dwelling (Main House) with an additional detached living area (Pool House)

The following were observed/inspected:
· COVID-19 signs are posted at the entrance. Visitors are screened in the main entrance and a log is kept.
· LPA was screened for this visit.
· Infection control signs and other COVID-19 signs are posted throughout the facility in the bathrooms, kitchen, and hallway to promote handwashing, cough/sneeze etiquette, and physical distancing.
· Facility has isolation room.
· 4 client rooms, common areas, bathrooms, and outdoor physical plant was inspected.
· No client rooms are equipped with alcohol-based hand sanitize but available at facility
· Four (4) centrally stored client medication records were reviewed.
· Staff responsible for direct care and supervision were observed wearing masks.
· Clients were not at facility at time of visit but 1 arrived later.
· Sufficient supply of perishable for 2 days but non-perishable foods for 7 days were not observed.
· A posted Emergency Disaster Plan was observed posted at facility.
· PPE's were observed.
· Staff and resident files were not reviewed during today's visit.
The following deficiencies were observed to be in violation of California code of Regulations, Title 22, Division 6 (refer to 809D)
Exit interview was conducted with Administrator James Calhoun. A copy of the report was provided.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2022
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 02/10/2022 02:10 PM - It Cannot Be Edited


Created By: Alberto Lopez On 02/10/2022 at 01:38 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: T R E HOME I
FACILITY NUMBER: 197609591

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2022

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 and water mesurments, the licensee did not comply with the section cited above in 4 counts which poses an immediate health, safety or personal rights risk to persons in care. Kitchen was measured at 140.1 degress. Client bathroom number 1 was measured at 140.5 degress F, Large bathroom was measred at 139.9 F degrees and rear house sick was measured at 121.2 degrees F. Water readings were witnessed by Keyrhon King DSP.
POC Due Date: 02/11/2022
Plan of Correction
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Administrator will adjust water heater and provide picutres of readings fro 7 days.
Type A
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, LPA did not obeserve non perishable foods for seven days. .
POC Due Date: 02/11/2022
Plan of Correction
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Administrator will purchase 7 days of non- perishable foods and send photo of receipt to LPA by POC 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:Christine Yee
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/10/2022 02:10 PM - It Cannot Be Edited


Created By: Alberto Lopez On 02/10/2022 at 01:38 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: T R E HOME I
FACILITY NUMBER: 197609591

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85087.2(b)
Outdoor Activity Space
(b) The outdoor activity area shall provide a shaded area, and shall be comfortable, and furnished for outdoor use.

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 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/10/2022
Plan of Correction
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Administrator will purchase furniture with shade and send receipt to LPA by POC date. Also, send photo of the furniture
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:Christine Yee
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2022


LIC809 (FAS) - (06/04)
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