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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801459
Report Date: 06/15/2023
Date Signed: 06/15/2023 12:28:40 PM

Document Has Been Signed on 06/15/2023 12:28 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: 4CENSUS: 4DATE:
06/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:57 AM
MET WITH:Guadalupe Sahagun, AdministratorTIME COMPLETED:
12:35 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 using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Administrator Guadalupe Sahagun. There are four (4) ambulatory developmentally disabled residents in the home. The facility is licensed as a level 2 Adult Residential Facility (ARF) vendored by Eastern 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, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention.

Infection Control:

  • Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor screening station at the entrance of the facility in place. The office room is designated as a COVID-19 isolation room if needed. Infection Control Plan and COVID-19 Mitigation Plan have been submitted.


Physical Plant/Environment Safety:
  • The facility is a single story home located in a residential neighborhood that is licensed for four (4) ambulatory residents. It consists of 6 bedrooms [3 designated for residents 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 interior and exterior physical plant was inspected. Exit doors are free of any obstruction. Smoke and carbon monoxide detectors are operational. The facility has one (1) fully charged fire extinguisher. Cleaning supplies and toxic substances are inaccessible to residents.

  • Water temperature readings measured between the required 105 - 120 degrees Fahrenheit.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2023
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 REFUGIO
FACILITY NUMBER: 197801459
VISIT DATE: 06/15/2023
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
26
27
28
29
30
31
32
Operational Requirements:
  • The updated Program Design was reviewed. Licensee was advised to submit a copy to CCL to reflect changes in capacity and additions made to the plan of operation.
  • On 6/28/2022, fire clearance was approved by LA County Fire Department for four (4) ambulatory residents.
  • Care and supervision to meet the resident needs was observed. No special equipment was observed.
  • Surety Bond was is current in the amount of $1,000.00.

Staffing:
  • A total of three (3) staff members provide care and supervision to residents. The facility is owner operated.

Personnel Records/Staff Training:
  • Administrator certificates expired 4/1/2023. Proof that recertification class credit documents were submitted to the recertification unit on 3/20/2023 was reviewed. Licensee has not received a current certificate.
  • Two (2) staff files were reviewed for criminal background clearance and training.
  • Personnel records were reviewed for health/TB screenings, certifications, and 1st Aid/CPR training. Staff (2) and staff (S3) do not have current 1st Aid/CPR training. Citation was issued.

Resident Rights/Information:
  • No Physician orders for postural supports are in place.

Resident Records/Incident Reports:
  • Four (4) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, IPP reports, personal rights, medical consent, nutritional assessments, medication records, Restricted Health Care Plans, and P & I money were reviewed.

Food Service:
  • The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.
  • Residents do not have any modified diets.

See next page.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 REFUGIO
FACILITY NUMBER: 197801459
VISIT DATE: 06/15/2023
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
26
27
28
29
30
31
32
Health Related Services:
  • Residents are assisted with self administration of prescription and non-prescription medications.
  • Three (3) centrally stored resident medication records were reviewed. Centrally stored medications are kept in a safe and locked place not accessible to clients in care. Medications are given according to Physician directions.

Incident Medical and Dental:
  • All residents have a Needs and Services Plan an on file.
  • Staff training was on file.

Disaster Preparedness, and Emergency Intervention:
  • A posted Emergency Disaster Plan LIC 610D containing emergency evacuation information was observed. However, the most current LIC 610D required has not been completed. A technical advisory was issued.
  • An emergency drill was conducted on 5/13/2023. The facility shall conduct a drill at least quarterly for each shift.


Emergency Intervention:
  • No manual restraints or seclusion are used on residents in care.


No deficiencies cited.

Exit interview conducted with Administrator Guadalupe Sahagun. A copy of the report and technical advisory was issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 06/15/2023 12:28 PM - It Cannot Be Edited


Created By: Noemi Galarza On 06/15/2023 at 12:06 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: 06/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in that staff (S2 & S3) do not have current 1st Aid/CPR cards on file; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/06/2023
Plan of Correction
1
2
3
4
Administrator agreed to submit proof of 1st Aid/CPR cards.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 06/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2023


LIC809 (FAS) - (06/04)
Page: 4 of 4