<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801459
Report Date: 11/09/2021
Date Signed: 11/09/2021 02:50:01 PM

Document Has Been Signed on 11/09/2021 02:50 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CASA SAHAGUN NUESTRO REFUGIOFACILITY NUMBER:
197801459
ADMINISTRATOR:GUADALUPE E. SAHAGUNFACILITY TYPE:
735
ADDRESS:14136 BRONTE DRIVETELEPHONE:
(562) 945-5530
CITY:WHITTIERSTATE: CAZIP CODE:
90602
CAPACITY: 6CENSUS: 5DATE:
11/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:38 PM
MET WITH:Guadalupe SahagunTIME COMPLETED:
02:55 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Administrator Guadalupe Sahagun and explained the purpose of the visit. There are five (5) level 2 developmentally disabled clients ages 18-59. The facility is serviced by Eastern Los Angeles Regional Center. The facility is a owner operated single story home located in a residential neighborhood that is licensed for 6 ambulatory clients. It consists of 6 bedrooms [3 designated for clients and 3 for family use], living room, family room, dining room, kitchen, laundry room, covered backyard deck area, and gated self-latching swimming pool. The office room in the attached garage is presently being used as an additional bedroom for licensee's family member. The last fire drill was conducted on 10/16/2021. Administrator certificate expires 4/1/2023.

The following were observed/inspected:
  • The interior and exterior physical plant was inspected. An unlocked BB gun was observed in a bedroom used by Licensee's family next to the garage. In addition, client (C1's) noon medications were observed to be unlocked on top of the client's night stand accessible to other clients in care.
  • COVID-19 Infection Control signs were observed in the entrance and bathrooms. Infection control screening items are kept in the kitchen area.
  • Each client's room is designated as a COVID-19 isolation room if needed.
  • Four (4) centrally stored resident medication records were reviewed.
  • Staff was observed wearing a surgical mask.
  • Clients in care do not wear masks because it is not tolerated due to cognitive impairment.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
  • A posted Emergency Disaster Plan was observed.
  • Sufficient supply of Personal Protective Equipment (PPEs) was observed.
  • Staff and resident files were not reviewed during today's visit.
Deficiencies were cited.
Exit interview was conducted with Administrator Guadalupe Sahagun. A copy of the report and appeal rights was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2021
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 2
Document Has Been Signed on 11/09/2021 02:50 PM - It Cannot Be Edited


Created By: Noemi Galarza On 11/09/2021 at 02:23 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: CASA SAHAGUN NUESTRO REFUGIO
FACILITY NUMBER: 197801459

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)(1)
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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above, at 1:12 PM LPA observed an unlocked BB gun and pallets on top of the dresser of a bedroom presently being used by licensee's family member where the office was located. Administrator stated that the room is not accessed by clients in care. However, the door to the room does not require a key to enter, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/10/2021
Plan of Correction
1
2
3
4
Licensee/Administrator shall submit a written statement stating how it was corrected. Submit picture proof evidence that the dangerous item was locked.
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in that at 1:10 PM, LPA observed client (C1's) noon medications on top of the nightstand next to the client. Administrator stated they were dispensed earlier. Per Administrator, the client receives the noon medications first, eats lunch, and then takes the medications. However, the medications were left unlockled readily accessible to other clients in care, which poses an immediate health, safety or personal rights risk to persons in care.

which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/10/2021
Plan of Correction
1
2
3
4
Administrator/Licensee shall submit a written statement regarding medication administration protocols, and the plan of correction.
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:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2021


LIC809 (FAS) - (06/04)
Page: 2 of 2