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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801459
Report Date: 06/29/2022
Date Signed: 06/29/2022 02:48:38 PM

Document Has Been Signed on 06/29/2022 02:48 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: 4DATE:
06/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:59 PM
MET WITH:Guadalupe Sahagun, Administrator TIME COMPLETED:
02:15 PM
NARRATIVE
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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 four (4) 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 only clients. LPA conducted an exterior and interior physical plant tour. It consists of 6 bedrooms [3 designated for clients and 6 for family use], living room, family room, dining room, kitchen, laundry room, weight training 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 #7 for licensee's family member. The last fire drill was conducted on 6/10/2033. Administrator certificate expires 4/1/2023.

Observations:
  • COVID-19 Infection Control signs were observed in the entrance and bathrooms. Infection control screening items are kept in the family room.
  • Bedroom #4 is designated as the COVID-19 isolation room if needed.
  • Four (4) centrally stored resident medication records were reviewed. Facility maintains a 30-day supply of medications.
  • Sharps and chemicals/cleaning supplies are stored inaccessible to residents.
  • 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.
  • Discarded furniture debris was observed in the side of the facility.
A deficiency was 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: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2022
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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Document Has Been Signed on 06/29/2022 02:48 PM - It Cannot Be Edited


Created By: Noemi Galarza On 06/29/2022 at 02:22 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: 06/29/2022

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, the licensee did not comply with the section cited above in that the side yard had discarded furniture and debris; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/20/2022
Plan of Correction
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Licensee shall remove the discarded items and submit picture proof evidence to LPA by POC due date.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2022


LIC809 (FAS) - (06/04)
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