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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609804
Report Date: 07/29/2023
Date Signed: 07/29/2023 05:08:12 PM

Document Has Been Signed on 07/29/2023 05:08 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:ALLIANCE ADULT RESIDENTIAL HOMES INCFACILITY NUMBER:
197609804
ADMINISTRATOR:WAKABI, MOSES DFACILITY TYPE:
735
ADDRESS:7821 HESPERIA AVENUETELEPHONE:
(747) 254-4154
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 4CENSUS: 4DATE:
07/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Moses Wakabi, AdministratorTIME COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced required annual inspection. LPA met with David Akuguzibwe and Habiba Alkhusaiby, Direct Support Professionals (DSPs) and explained the purpose of the visit. The facility is licensed to care for Developmentally Disabled Adults, ages 18 through 59, (4) ambulatory only. All clients residing at this facility receive case management services provided by North LA Regional Center. At 2:00pm, Moses Wakabi/Administrator arrived and assisted LPA with the inspection. 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 observed. There is a visitor screening station at the entrance of the facility. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Bathrooms have soap and paper towels. Staff perform hand hygiene practices and are adhering to infection control requirements.
Physical Plant/Environment Safety: The facility is a single storey home located in a residential neighborhood, contains a total of (4) client bedrooms, two (2) full bathrooms, a living room, kitchen, dining area, backyard, and attached garage. Currently, there are four (4) clients living in the facility. Facility is a Level 4G. The interior and exterior physical plant was inspected. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, and sufficient closet space. Bathrooms have non-skid materials and contained hygiene supplies including liquid soap, paper towels, and toilet paper. Exit doors are free of any obstruction and there are no pools or large bodies of water. Attached garage stores PPE supplies, an extra refrigerator and freezer, and emergency food supplies. Kitchen knives, sharps objects, cleaning supplies and toxic substances are locked in the cabinet under the sink and inaccessible to clients. There is one (1) fire extinguisher observed mounted on the post next to the dining area and purchased on 8/26/2021. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. There are no cameras in the facility. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Hot water supply measured 107.1 deg F in bathroom #1, and 108.3 deg F in bathroom #2.
Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. Surety Bond Insurance (Western Surety) is valid and expires on 02/01/2027.Liability Insurance policy (policy # 9270108-2023) in the amount of $1,000,000.00 each occurrence and $3,000,000.00 in the total annual aggregate expired on 6/29/2023. Administrator showed an email from the insurance company to prove that liability insurance is being renewed.Fire Drill was last conducted on 01/15/2023. Outdoor space/backyard was inspected and has a shaded area and sitting area.
*****REPORT CONTINUED ON LIC809-C****
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2023
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 4
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: ALLIANCE ADULT RESIDENTIAL HOMES INC
FACILITY NUMBER: 197609804
VISIT DATE: 07/29/2023
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Staffing: A total of five (5) staff members plus the Administrator provide care and supervision to the clients. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. (2) of the staff members, Tonny Onyango and Abdul Mumin were not associated in the facility. Administrator provided LIC 508 and fingerprint clearance for Tonny Oyyango showing that he has been cleared. According to the Administrator, they are in the process of hiring Abdul Mumin who is present in the facility during the visit. Abdul and Administrator were scheduled to meet today to fill out employment forms.
Personnel Records/Staff Training: Reviewed files for two (2) staff. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Administrator certificate is valid and expires on 2/04/2024. LPA conducted (2) staff interviews.
Client Rights-Information: Client personal rights are posted. Facility provides internet services to all clients and have access to the facility phone. All four (4) clients have personal cell phones and two (2) out of four (4) clients have computers/laptop. LPA conducted (2) client interviews.
Client Records-Incident Reports: LPA reviewed Client files for C1 through C2. Client files are maintained at the facility. Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Individual Program Plan (IPP), Behavioral Reports, Functional Assessment, Needs & Services Plan, Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights observed. Food Service: There are sufficient food supplies of 2-day perishable and 7-day non-perishable items. The food is properly stored in the refrigerator (clean and well maintained). There are no clients with special diets residing at this facility. Pesticides and cleaning supplies are kept away from the food preparation areas and kept in locked storage room outside. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.
Health Related Services: The medications are centrally stored and in their original containers. Medications were reviewed for C1-C2 to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubbled packed and stored in plastic bins.
Incidental Medical Services: According to the Administrator, there are no clients at this home with incidental medical services nor have a restricted health condition.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan. Emergency Intervention: Not-Applicable.

Pursuant to Title 22, deficiencies were cited on the attached 809D. An exit interview was conducted, and a copy of this report was provided to Moses Wakabi, Administrator.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/29/2023 05:08 PM - It Cannot Be Edited


Created By: Bennette Pena On 07/29/2023 at 03:28 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: ALLIANCE ADULT RESIDENTIAL HOMES INC
FACILITY NUMBER: 197609804

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the Administrator did not comply with the section cited above in that the fire extinguisher mounted on the post next to the dining area has expired with a purchase receipt dated 8/26/2021 which poses an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 07/31/2023
Plan of Correction
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Administrator shall submit proof of new fire extinguisher and provide purchase receipt to 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: 07/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/29/2023 05:08 PM - It Cannot Be Edited


Created By: Bennette Pena On 07/29/2023 at 03:28 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: ALLIANCE ADULT RESIDENTIAL HOMES INC
FACILITY NUMBER: 197609804

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the Administrator did not comply with the section cited above in which the last fire drill was conducted on 1/15/2023, which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 08/04/2023
Plan of Correction
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Administrator will conduct fire drills once every three months. Administrator will set quarterly reminders by posting a fire drill calendar as a reminder. Administrator will provide LPA proof of the an updated Fire/Disaster Drill signed and dated by staff 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: 07/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2023


LIC809 (FAS) - (06/04)
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