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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197800850
Report Date: 12/11/2023
Date Signed: 12/11/2023 03:39:48 PM

Document Has Been Signed on 12/11/2023 03:39 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: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: 3DATE:
12/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Co-Administrator Robyn WilliamsTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 12/11/2023. LPA Ramirez was met by Staff Robyn Williams and explained the purpose of the visit. The facility is licensed serve four (4) ambulatory developmentally disabled clients 18-59 years old. LPA Ramirez requested and obtained copies of Personnel Report (LIC 500), and Client Roster (LIC 9020). All clients in the facility receive services from San Gabriel/Pomona Regional Center.

LPA OBSERVATIONS: Tour began at 8:37 am. The facility is a single-story dwelling located in a residential area with four (4) client bedrooms, one (1) staff office, three (3) bathrooms, kitchen, dining room, living room, front yard, and backyard.

Front Yard: LPA Ramirez observed front yard to be free of hazards. Front yard was well maintained.

Kitchen: LPA Ramirez observed appliances to be in working order. LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed a fully charger fire extinguisher nearby. Kitchen sink temperature was measured at 112.8 degree F. LPA Ramirez observed several dead brownish insects in upper/lower cabinets near sink. LPA Ramirez observed several large brown insects crawling in pantry.

Dining Room/Living room: Dining room was observed to contain one table with four (4) chairs. Living room was observed to contain plenty of lighting. LPA Ramirez observed a fully charged fire extinguisher nearby. LPA Ramirez observed signage promoting cough and handwashing etiquette in this area. LPA Ramirez observed nearby thermostat to read 79 degrees F.

Linen Closet/Supply Closet: Observed to contain plenty linens, towels, and hygiene products.

Client Rooms 1 - 4: LPA Ramirez observed client bedrooms#2-4 to contain the required linens, furnishings, and lighting. Client bedroom#1 ceiling light was not operable. Several blinds in client bedroom#1 window were missing. All client bedrooms are private. Client bedroom#2 was accessible and observed unoccupied. LPA Ramirez observed three (3) cans of paint in client bedroom#2 in closet and was made accessible to three (3) out of three (3) clients in care.

SEE 809-C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2023
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: PAYNE CARE CENTER
FACILITY NUMBER: 197800850
VISIT DATE: 12/11/2023
NARRATIVE
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Bathroom 1-3: LPA Ramirez observed non slip mats in all bathrooms showers. LPA Ramirez observed signage promoting proper handwashing etiquette near sink. Water temperature in bathroom#1 was measured at 112.1 degree F. Bathroom#2 located in client bedroom#3, water temperature was measured at 112.8 degree F. Bathroom#3 located in client bedroom# 4, was measured at 116.8 degree F.

Backyard: No large bodies of water were observed and area was free of hazards.

Emergency Drills: No proof of documented drills was provided.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide and smoke detectors in hallways. Smoke detectors were observed to be operable during visit.

Personnel Records: Not all personnel records were maintained at the facility. LPA Ramirez reviewed five (5) personnel records. Administrator Certificate for Lavonia Williams (6004324735) is pending. Personnel record for Lavonia Williams was not observed at facility or reviewed.

Client Files: Client files were not maintained at facility.

Infection Control Plan: LPA Ramirez reviewed current infection control plan.

Exit interview was conducted. A copy of this report, 809-D, LIC 9102, and appeals rights was provided.

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

DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 12/11/2023 03:39 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 12/11/2023 at 12:17 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: 12/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)(1)
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. (1) The licensee shall take measures to keep the facility free of flies and other insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, several dead and crawling insects were seen in kitchen cabinets, the licensee did not comply with the section cited above in 3 out of 3 clients, employees and visitors, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/29/2023
Plan of Correction
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Licensee will contact current pest control services and advise of insect infestation in facility kitchen. Licensee will provide written feed back or updated pest control contract by 12/29/23 via email. Licensee will instruct staff to clean and disinfect inside cabinets where insects were observed. Licensee will send pictures via email of cleaned cabinets by 12/29/23.
Type B
Section Cited
CCR
80088(d)
Fixtures, Furniture, Equipment, and Supplies
(d) The licensee shall provide lamps or lights as necessary in all rooms and other areas to ensure the comfort and safety of all persons in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, client bedroom#1 ceiling light was not operable, the licensee did not comply with the section cited above in 1 out of 3 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/15/2023
Plan of Correction
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Licensee will replace bulb by 12/15/23 and send picture proof to LPA Ramirez via email.
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: 12/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2023


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 12/11/2023 03:39 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 12/11/2023 at 12:17 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: 12/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(d)
Client Records
(d) All client records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, 3 out of 3 client records were not available upon demand to inspect, audit, and copy, facility and the licensee did not comply with the section cited above in 3 out of 3 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/15/2023
Plan of Correction
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Licensee will certify plan to address future availiability of client records.
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, LPA Ramirez did not observe documentation of quarterly drills, the licensee did not comply with the section cited above in 3 out of 3 clients, staff and visitors, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/15/2023
Plan of Correction
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Licensee will provide documentation of drill via email.
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: 12/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2023


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 12/11/2023 03:39 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 12/11/2023 at 12:43 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: 12/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(e)
80066(e) Personnel Records
All personnel records shall be maintained at the facility site and shall be available to the licensing agency for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA Ramirez did not review Administrator Lavonia Williams due to record not at facility site,the licensee did not comply with the section cited above in 3 out of 3 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/15/2023
Plan of Correction
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Licensee will certify plan to address Administrator file being maintained at facility.
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: 12/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2023


LIC809 (FAS) - (06/04)
Page: 6 of 6