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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197800850
Report Date: 01/14/2023
Date Signed: 01/17/2023 10:25:49 AM

Document Has Been Signed on 01/17/2023 10:25 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PAYNE CARE CENTERFACILITY NUMBER:
197800850
ADMINISTRATOR:WILLIAMS, LAVONIA PAYNEFACILITY TYPE:
735
ADDRESS:181 E. ARROW HIGHWAYTELEPHONE:
(909) 506-4428
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 4CENSUS: 4DATE:
01/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:16 PM
MET WITH:House Manager Darlene CarcobaTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA was met by House Manager Darlene Carcoba and explained the reason for the visit. LPA was later met by Administrator Lavonia Williams. There are four (4) level 4e developmentally disabled clients in the home. The facility is licensed for clients 18-59 years old. There are 2 residents over the age of 60 years old. The facility is located in a residential area. A tour of the single-story facility includes: Living room, kitchen/laundry area, dining area, 4 Client bedrooms, 3 bathrooms, staff room and a detached garbage/office/storage.

LPA observed the following:
· All outdoor and indoor passageways are free of obstruction.
· COVID-19 Infection Control signs were observed in the entrance and bathrooms. Screening protocols are in place. Clients in care do not wear a mask because it is not tolerated due to cognitive impairment.
· Four (4) centrally stored resident medication records were reviewed. Facility maintains a 30-day supply of medications. LPA observed medications to be unlocked and accessible to clients during visit. During medication review LPA observed C1, C2, C3, C4 all had medication that was administered on 01-13-23 at PM but not initialed by staff. LPA observed C1, C2, C3, C4 all had medication administered on 01-14-23 at AM but was not initialed by staff.
· Kitchen water measured at 109.5 degrees F which in with the required 105 – 120 degrees F. Kitchen cabinet drawer located near sink is missing. Knives and sharps were observed in an unlocked cabinet and accessible to clients during visit. Nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days were observed.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2023
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 7
Document Has Been Signed on 01/17/2023 10:25 AM - It Cannot Be Edited


Created By: Kimberly Ramirez On 01/14/2023 at 03:20 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: PAYNE CARE CENTER
FACILITY NUMBER: 197800850

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, kitchen cabinet drawer located near sink is missing, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/21/2023
Plan of Correction
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Administrator/Licensee will replace cabinet and provide photo proof.
Type B
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, knives and sharps were observed in an unlocked cabinet and accessible to clients during visit, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/21/2023
Plan of Correction
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Administrator/Licensee will re-train staff and send proof of training to LPA. Staff locked cabinet before LPA exited facility.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/17/2023 10:25 AM - It Cannot Be Edited


Created By: Kimberly Ramirez On 01/14/2023 at 03:54 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: PAYNE CARE CENTER
FACILITY NUMBER: 197800850

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation,LPA observed medications to be unlocked and accessible to clients during visit, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/21/2023
Plan of Correction
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Administrator/Licensee will ensure staff keep medications locked at all times. Administrator/ Licensee will re-train staff and provide proof of trainig.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2023


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 01/17/2023 10:25 AM - It Cannot Be Edited


Created By: Kimberly Ramirez On 01/14/2023 at 04:19 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: PAYNE CARE CENTER
FACILITY NUMBER: 197800850

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)(5)(B)
(B) Once ordered by the physician the medication is given according to the physician's directions

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation,C1, C2, C3, C4 all had medication that was administered on 01-13-23 at PM but not initialed by staff. LPA observed C1, C2, C3, C4 all had medication administered on 01-14-23 at AM but was not initialed by staff, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/21/2023
Plan of Correction
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Administrator/Licensee will re-train staff on how to properly administer medication and send proof of training and acknowledgment that all staff received training.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2023


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: PAYNE CARE CENTER
FACILITY NUMBER: 197800850
VISIT DATE: 01/14/2023
NARRATIVE
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· Smoke detectors were tested and are operational. Fire extinguishers are fully charged. The facility has a fire pull alarm system.
· All client bedrooms contained the required furniture, linen, and lighting.
· Client bathroom# 1 water temperature measured at 107.1 degrees F which in within the required 105 – 120 degrees F. Client bathroom #2 located client bedroom # 2 water temperature was measured at 118.7 degrees F which in within the required 105 – 120 degrees F. Client bathroom #3 located in client bedroom #4 water temperature was measured at 114.0 degrees F which is within the 105 – 120 degrees F.

Deficiencies are being cited. See LIC 809D. Exit interview was conducted with House Manager Darlene Carcoba. A copy of the report/appeal rights was issued.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2023
LIC809 (FAS) - (06/04)
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