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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197800093
Report Date: 07/07/2024
Date Signed: 07/07/2024 11:17:37 AM

Document Has Been Signed on 07/07/2024 11:17 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:DUBESOR HOMESFACILITY NUMBER:
197800093
ADMINISTRATOR/
DIRECTOR:		JOSEFINA O. TEODOROFACILITY TYPE:
735
ADDRESS:15651 DUBESOR STREETTELEPHONE:
(626) 917-1874
CITY:VALINDASTATE: CAZIP CODE:
91744
CAPACITY: 6CENSUS: 5DATE:
07/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Administrator Josefina TeodoroTIME VISIT/
INSPECTION COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met Administrator Josefina Teodoro and the purpose of the visit was discussed. The facility is approved for serve Developmentally Disabled Adults 18-59 years old only and ambulatory only.

The following twelve (12) tool domains were completed:
1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility still encourages hand washing. The facility has a COVID-19 mitigation plan in place but will need to completed an Infection Control Plan.

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. Client bedrooms observed to have required furniture and beddings, 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 115 degrees F which is within the Title 22 regulation. LPA inspected the carbon monoxide detectors and smoke detectors to be functioning properly. The walkway, passageway and the patio are free of obstruction. The cleaning supplies and all other chemicals are locked and inaccessible to clients in care. The extra linens and the personal hygiene products observed. 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 a telephone system in the premises.

3. Operational Requirements: The facility is only approved for ambulatory only. Currently all five (5) clients are ambulatory. Fire drills conducted quarterly. The facility has a shaded area in the patio/backyard with table and chairs for client to utilize for outdoor activity.

Continued on LIC 809-C
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2024
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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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: DUBESOR HOMES
FACILITY NUMBER: 197800093
VISIT DATE: 07/07/2024
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4.Staffing: The facility has sufficient staffing to provide care and supervision. The administrator is the live in staff in the facility and has updated facility planned emergency procedure training.

5.Personnel Records-Training: All the facility staff files are maintained in the facility. The administrator is Josefina Teodoro and her administrator certificate expired on 12/15/2022. Administrator has completed training's but has not submitted packet to the department for renewal. LPA reviewed (4) Staff files. Required documents observed on file.

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. LPA reviewed five (5) 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.

9. Health Related Services: All the clients medication are centrally stored and inaccessible to clients in care. LPA inspected all five (5) client medication. No medication errors observed

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 facility has two appropriate temporary shelter location.

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

Per Title 22 Regulations, a deficiency us being cited. Please see attached LIC 809-D page. Exit interview conducted, a copy of the report and appeal rights given to administrator Josefina Teodoro.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/07/2024 11:17 AM - It Cannot Be Edited


Created By: Jose Villalobos On 07/07/2024 at 10:51 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: 07/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(b)
Administrator Qualifications and Duties
(b) All adult residential facilities shall have a qualified and currently certified administrator.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as Administrator Certificate for Josefina expired in 2022 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/22/2024
Plan of Correction
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Administrator to submit Administrator renewal packet to the department and provide LPA a copy by the 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:Fernando Fierros
LICENSING EVALUATOR NAME:Jose Villalobos
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2024


LIC809 (FAS) - (06/04)
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