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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197800835
Report Date: 01/16/2024
Date Signed: 01/16/2024 03:03:22 PM

Document Has Been Signed on 01/16/2024 03:03 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:HEGLIS CARE HOMEFACILITY NUMBER:
197800835
ADMINISTRATOR:JANE ANNE CUAFACILITY TYPE:
735
ADDRESS:3218 HEGLIS AVE.TELEPHONE:
(626) 280-0061
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY: 4CENSUS: 4DATE:
01/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:59 AM
MET WITH:Maria Ruga and Gil CalingasanTIME COMPLETED:
03:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced visit at the facility for the purpose of conducting the required annual inspection. LPA utilized the Compliance and Regulatory Enforcement (CARE) Tool to evaluate the facility. LPA Lopez met with House Manager Maria Ruga and designated temporary Administrator Gil Calingasan LPA explained the purpose for the visit.

The facility is licensed to serve 4 ambulatory developmentally disabled clients aged 18 to 59. Currently, there are four (4) clients in placement. All clients residing at this facility receive case management services provided by East Los Angeles Regional Center.

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 Services, Disaster Preparedness, and Emergency Intervention.

During the visit LPA observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has sufficient PPE supplies, has an Infection Control Plan and Mitigation Plan. Bathrooms have hand washing signs, soap and paper towels. Per Facility Administrator all staff also have the COVID-19 vaccines including boosters. Facility Administrator is adhering to infection control requirements.

Refer to LIC 809C for continuation of report
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2024
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HEGLIS CARE HOME
FACILITY NUMBER: 197800835
VISIT DATE: 01/16/2024
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Operational Requirements: Fire Drills are conducted every three months; the last fire drill was conducted on 11/08/2023. Emergency Disaster/ Earthquake Drills are conducted every three months and the last one was conducted on 11/08/2023. Facility staff conducts drills quarterly.

Physical Plant & Environment Safety: The home is located in a residential area, the single-story facility includes a living room, dining room, kitchen, laundry room, 4 client bedrooms, 2 restrooms, One staff ½ restroom an unattached garage and indoor/outdoor activity areas. LPA observed appropriate furniture, lighting fixtures, personal storage space as required, all beds have adequate amount of linen and mattresses, and box springs are in good repair. Bathrooms were found to be within Title 22 regulations. Toilets and water faucets worked properly. Bathroom sinks and showers were free of mold/mildew. LPA observed that sufficient toiletries accessible to clients. Water temperature measured between 105.4 – 106.3 degrees F which is within range of 105.0 – 120 Degrees F. Facility temperature was 61- and 62.6-degrees F which is not within range of 68 - 85. LPA observed the facility to be clean and appropriately furnished with clear passageways inside and outside. First aid kit is fully stocked with manual, smoke detectors and carbon monoxide detectors were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to clients. Hazardous toxins and/or items are inaccessible to clients, fire extinguisher(s) are fully charged. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. Exits were marked with signs. Notifications and postings were observed which included personal rights, visitor policy, complaint procedures, menu, and emergency disaster plan which needs updating.

Staffing: There is sufficient staffing at the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator, and S1-S3. Staff have current CPR/first aid training and sufficient on-going training that meets the annual requirement. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting. Administrator Certificate expired on 11/20/2023 Renewal was mailed on 11/17/2023 and pending.

Client Rights-Information: Client personal rights and House Rules are posted. Per Facility Administrator, facility provides wi-fi services for facility clients.



SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024
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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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HEGLIS CARE HOME
FACILITY NUMBER: 197800835
VISIT DATE: 01/16/2024
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Client Records-Incident Reports: LPA reviewed Client files for C1 through C4. Client files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Appraisal Needs and Services Plan, Functional Capabilities Assessment, Mental Health Intake Assessment, Client Cash Resources. Special Incident Reports, Client Personal Property and Clients Personal Rights and current IPPs.

Food Service: The facility has sufficient food supplies of 2-day perishable and 7 day supply of non-perishable items. The food is properly stored in the refrigerator which is clean and well-maintained. There are no clients with special diets residing at this facility. Kitchen is kept clean and free from rodents and other bugs/ insects. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services: The medications are centrally stored and in their original containers. LPA reviewed medication for C1-3. One client does not take medications. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubble packed and delivered monthly.

Incidental Medical Services: Per Facility Administrator, there are no clients at this home with incidental medical services or restricted health condition.

Disaster Preparedness: The facility has an Emergency Disaster Plan but needs updating.

Emergency Intervention: Not Applicable.

Deficiencies noted. Technical advisories also provided. Exit interview and a copy of this report, 809D and appeal rights was provided to Administrator Gil Galisan
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/16/2024 03:03 PM - It Cannot Be Edited


Created By: Alberto Lopez On 01/16/2024 at 02:34 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: HEGLIS CARE HOME
FACILITY NUMBER: 197800835

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(a)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) The licensee shall maintain the temperature in rooms that clients occupy between a minimum of 68 degrees F (20 degrees C) and a maximum of 85 degrees F (30 degrees C).

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. Facility temperature was 61 and 62.6 degrees F which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/16/2024
Plan of Correction
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Temperature was adjusted during visit. ***NO FURTHER ACTION REQUIRED***
Type B
Section Cited
HSC
1565(a)(6)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (6) The location of utility shutoff valves and instructions for use.

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. Emergency disaster plan needs updating, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/23/2024
Plan of Correction
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Administrator will update the facility emergency disaster plan and send 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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2024


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