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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197800093
Report Date: 07/20/2023
Date Signed: 08/02/2023 02:30:43 PM

Document Has Been Signed on 08/02/2023 02:30 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:DUBESOR HOMESFACILITY NUMBER:
197800093
ADMINISTRATOR:JOSEFINA O. TEODOROFACILITY TYPE:
735
ADDRESS:15651 DUBESOR STREETTELEPHONE:
(626) 917-1874
CITY:VALINDASTATE: CAZIP CODE:
91744
CAPACITY: 6CENSUS: 3DATE:
07/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Josefina Teodoro TIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Wong conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met Administrator Josefina Teodoro and explained the reason of the visit and the administrator also assisted with the visit. The facility is approved for serve Developmentally Disabled Adults 18-59 years old only and ambulatory only. The facility is licensed as a level 2 vendored by San Gabriel Pomona Regional Center.

The following twelve (12) tool domains were observed and reviewed: Infection Control, Physical Plant/Environmental Safety, Operational Requirements, Staffing, Personal Records-Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incidental Medical Services, Disaster Preparedness and Emergency Intervention.

1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility still encourages hand washing. The facility has an Infection Control Plan and COVID-19 mitigation plan in place.

2. 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, family room, administrator bedroom, three clients bedrooms and one client bathroom. 1st and 3rd bedroom has two beds, two drawers, night stand, required furniture and beddings, sufficient lighting and closet space. 2nd bedroom has one bed, one night stand, one chair, drawer, required bedding and furniture and sufficient lighting and closet space. The client bathroom is clean, sanitary and in a good working condition. The hot water temperature in the client bathroom was tested at 125.7 degrees F which is over the Title 22 regulation. LPA inspected the carbon monoxide detectors and smoke detectors and they are all working probably. The walkway, passageway and the patio are free of obstruction.
(See LIC809C for continuation)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2023
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 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: DUBESOR HOMES
FACILITY NUMBER: 197800093
VISIT DATE: 07/20/2023
NARRATIVE
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The cleaning supplies and all other chemicals are locked under the sink and the locked cabinet in the garage. The extra linen is stored in the hallway cabinet and the extra personal hygiene products is stored in the garage. All the appliances in the living room and kitchen are working well. The hallway light is always on during the night time. The facility also has flash light for emergency use. The facility also has a telephone system in the premises.

3. Operational Requirements: The facility is only approved for ambulatory only. Currently all 3 clients are ambulatory. The last fire/disaster drill was conducted on 3/11/23. The facility has a shaded area in the patio/backyard with table and chairs for client to utilize for outdoor activity.

4.Staffing: The facility has sufficient staffing to provide care and supervision. The administrator is the live in staff in the facility and she does have the updated facility planned emergency procedure training.

5.Personnel Records-Training: All the facility staff files are maintained in the facility and stored in the file cabinet next to the administrator desk. All the staff are over 18 years old and criminal background cleared and associated with the facility. The administrator is Josefina Teodoro and her administrator certificate expired on 12/15/2022 and she does not have her updated HIV and TB training certificate. The staff has an updated First Aid Certificate and other required training.

6.Client's Right: The facility does not have any client with postural support at the present time. The facility does serve adults has internet service shall provide at least one access device.

7.Client's Records-Incident Reports: All the clients files are maintained in the facility and stored in the file cabinet next to the administrator desk. LPA inspected all three (3) clients files and they all have the required documents which are included: admission agreement, functional capabilities assessment, updated physician report, Individual Personalized Plan (IPP), ambulatory status and medication list ..etc

8.Food Service: Facility has sufficient food supply is stored in the kitchen and the garage consisting of: 2-day perishables, 7-day non-perishables. The refrigerator is maintained in the required temperature. All the food are stored probably.

(See LIC809C for continuation)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023
LIC809 (FAS) - (06/04)
Page: 2 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: DUBESOR HOMES
FACILITY NUMBER: 197800093
VISIT DATE: 07/20/2023
NARRATIVE
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9. Health Related Services: All the clients medication are centrally stored in the kitchen cabinet next to the refrigerator and its locked and inaccessible to clients. LPA inspected all three (3) clients medication and they are all seemed accurate and updated.

10. Incidental Medical Services: The facility currently does not have any clients with any prohibited health condition or restricted health condition.

11. Disaster Preparedness: The facility has an emergency and disaster plan in place. The last disaster drill was conducted on 3/11/23 and the facility has two appropriate temporary shelter location.

12. Emergency Intervention: The facility is not using any restraint in the facility.


Per Title 22 Regulations, the following deficiencies are being cited.

Exit interview conducted, a copy of the report and appeal rights given to administrator Josefina Teodoro.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 08/02/2023 02:30 PM - It Cannot Be Edited


Created By: Christine Wong On 07/20/2023 at 11:55 AM
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: DUBESOR HOMES
FACILITY NUMBER: 197800093

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2023

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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4
Based on LPA's observation, LPA observed the client bathroom hot water temperature was tested at 125.7 degrees which is over the Title 22 regulation.
POC Due Date: 07/21/2023
Plan of Correction
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The administrator will fix the hot water heater immediately and will send the 7 days hot water log till 7/27/23 to LPA via mail or email.
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:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 08/02/2023 02:30 PM - It Cannot Be Edited


Created By: Christine Wong On 07/20/2023 at 11:55 AM
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: DUBESOR HOMES
FACILITY NUMBER: 197800093

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(k)
Administrator Qualifications and Duties
(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on documents reviewed, LPA observed the administrator does not have an updated HIV and TB certificate in file. The last one was dated on 2013.
POC Due Date: 08/03/2023
Plan of Correction
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The administrator will send the updated HIV and TB certiciate 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:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2023


LIC809 (FAS) - (06/04)
Page: 5 of 5