197800792-9-5-2024-28-AS-DKOI-D8TQFK-20240905120804

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197800792
Report Date: 09/05/2024
Date Signed: 09/05/2024 12:08:49 PM

Document Has Been Signed on 09/05/2024 12:08 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	WHITTIER RESIDENTIAL HOME II		FACILITY NUMBER:	197800792
ADMINISTRATOR/ DIRECTOR:	GERARDO ZAMORA, JR.		FACILITY TYPE:	735
ADDRESS:	13971 GLENN DRIVE		TELEPHONE:	(562) 698-2957
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90605
CAPACITY: 4		CENSUS: 4	DATE:	09/05/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Gerardo Zamora, Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:20 PM

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Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Annual Required Visit on 09/05/2024.. LPA were met by Staff #1 (S1) and explained the purpose of the visit. S1 assisted in tour of facility. Administrator Gerardo Zamora arrived shortly after to the facility and was explained the purpose of the visit. The facility has a fire clearance approved for two (2) ambulatory and two (2) non-ambulatory clients. All clients receive services from East Los Angeles Regional Center. LPA observed Personnel Report and Resident Roster. The facility currently has 4 clients.

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

· Infection control practices and Personal Protective Equipment (PPEs) were observed.

· LPA observed that the facility has an infection control plan in place.

Physical Plant/Environment Safety:

· LPA conducted a tour of the facility with S1 and observed the following:

The facility is a single-story building in a residential area, with a kitchen, dining room, living room, two (2)
client shared bedrooms, one (1) staff bedroom, and the backyard with shaded area and a garage.
· All passageways, walkways, driveway, steps and patio are free from obstructions. The front, back and
side areas of the house are free of hazards.
· Hallway linen closet: Contained plenty of linens, towels. · PPEs and cleaning supplies are stored in a locked cabinet in the garage.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024

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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: WHITTIER RESIDENTIAL HOME II	FACILITY NUMBER: 197800792
	VISIT DATE: 09/05/2024

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· Beds have the required furniture including bedframes, dressers, lamps, and chairs. Beds have the required linen and the linen is in good condition.

· The facility has two (2) fully charged fire extinguishers located in the kitchen and one (1) fully charged fire extinguisher in the garage.

· Smoke/carbon monoxide detectors are tested and in working condition.

· Cleaning supplies are kept locked in the cabinet in the garage away from food supplies.
· Sharps are kept locked in the cabinet in the garage..
· Shared client bathrooms were observed to be clean and contained soap and paper towels.
· Restroom #1 (R1) had a hot water temperature reading measured at 113.5 Degrees F and Restroom #2 (R2) measured at 117.1 Degrees F which meets the required 105 Degrees F – 120 Degrees F per Title 22 Regulations.

Operational Requirements:
· The facility has a fire clearance approved for two (2) ambulatory and two (2) non-ambulatory
clients.

Staffing:
· A total of seven (7) full-time staff members provide care and supervision to the clients.

Personnel Records / Staff Training:

· Administrator’s certificate is effective to 05/22/2026

· LPA observed Administrator HIV & TB training on file.
· Five (5) staff files were reviewed for criminal background clearance and training.
· Personnel records have health/Tuberculosis (TB) screenings, certifications, and 1st Aid/CPR training.
· Facility has per regulation staff training in file.

Client Rights/Information:
· Physician orders were reviewed in client files.
· Phone and Internet access is available for the clients use.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024

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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: WHITTIER RESIDENTIAL HOME II	FACILITY NUMBER: 197800792
	VISIT DATE: 09/05/2024

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Client Records/Incident Reports:
· Four (4) client files were reviewed containing admission agreements, Physician’s Report, TB clearance, Individual Program Plan, personal rights, medication records, and Personal and Incidental (P & I) money were reviewed.

Food Services:

· The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.
· No restricted Health Care plan required for the clients in the facility.

Health Related Services:
· Clients are assisted with self-administration of prescription and non-prescription medications. · Four (4) centrally stored resident medication records were reviewed. · First Aid Kit was reviewed and has required items. · LPA observed cabinet located in the kitchen cabinet to be locked and inaccessible to residents. LPA reviewed four (4) out of four (4) client medications and Medication Administration Record (MAR).

Incidental Medical and Dental:
· All clients have a current Individual Program Plan, and COVID-19 vaccination cards on file.

Disaster Preparedness, and Emergency Intervention:
· A posted Emergency Disaster Plan LIC 610D containing emergency evacuation information was observed. · An emergency drill was last documented on 08/26/2024.

Emergency Intervention:

· No manual restraints or seclusion are used with clients in care.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided to the Administrator, Gerardo Zamora.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024

LIC809 (FAS) - (06/04)

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