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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801459
Report Date: 06/21/2024
Date Signed: 06/21/2024 11:34:21 AM

Document Has Been Signed on 06/21/2024 11:34 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CASA SAHAGUN NUESTRO REFUGIOFACILITY NUMBER:
197801459
ADMINISTRATOR/
DIRECTOR:		GUADALUPE E. SAHAGUNFACILITY TYPE:
735
ADDRESS:14136 BRONTE DRIVETELEPHONE:
(562) 945-5530
CITY:WHITTIERSTATE: CAZIP CODE:
90602
CAPACITY: 4CENSUS: 4DATE:
06/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:32 AM
MET WITH:Guadalup Sahagun, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:35 AM
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) Noemi Galarza made an unannounced annual inspection visit. The purpose of the visit was explained to Administrator Guadalupe Sahagun. The facility is a Adult Residential Facility (ARF) that serves level 2 developmentally disabled residents ages 59 and under, vendored by Eastern Los Angeles Regional Center. The facility is a single story home located in a residential neighborhood. 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 3 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 attached garage is presently being used as an additional bedroom #7 for licensee's family member. The following 12 (CARE) tool domains were utilized during the inspection.

Infection Control: An Infection Control Plan was reviewed. Visit screening is still in place.

Physical Plant/Environment Safety: The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. There is a gated pool. Smoke and carbon monoxide detectors were tested and are operation. The facility has one (1) fully charged fire extinguishers. Hot water temperature readings measured between the required 105 - 120 degrees Fahrenheit. Storage areas for cleaning solutions/toxins, knives, and hazardous items were inaccessible to clients.

* The stucco surrounding the electrical panel is broken and in need of repair.

Operational Requirements: Fire clearance is approved for four (4) ambulatory only residents. Care and supervision to meet the clients needs was observed. No special equipment and supplies are used by clients. Facility manages residents P & I monies. The Surety Bond expires 11/26/2024.



Staffing: A total of 2 staff members provide care and supervision to the clients.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2024
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 3
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: 06/21/2024
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
Personnel Records/Staff Training: Two (2) staff files were reviewed and contained criminal background clearance, in-service training, 1st Aid/CPR training, and health screening. Administrator certificate expires 4/1/2025.

Resident Rights/Information: Resident Personal Rights poster is posted in the kitchen area. Internet access is available for residents. Physician's orders are on file. One (1) resident has a modified diet order.

Resident Records/Incident Reports: Four (4) resident files were reviewed containing admission agreements, Physician's Reports, IPPs, medical/functional assessments, Behavior Reports, TB clearance, personal rights, medical consent, medication records, and P & I records.

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.

Health Related Services: Residents are assisted with self administration of prescription and non-prescription medications. Medications 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. 30-Day supply of medications were observed.

Incident Medical and Dental: All residents have a Needs and Services Plan and updated medical assessments.

Disaster Preparedness, and Emergency Intervention: A current LIC 610D updated form "Emergency Disaster Plan/Disaster and Mass Casualty Plan was reviewed.

The last Fire/Emergency Drill was conducted on 5/17/2024.

Emergency Intervention: No manual restraints, seclusion, or de-escalation techniques are used.

A deficiency was cited.


Exit interview was conducted with Guadalupe Sahagun. A copy of the report/appeal rights were provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/21/2024 11:34 AM - It Cannot Be Edited


Created By: Noemi Galarza On 06/21/2024 at 11:22 AM
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: 06/21/2024

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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in that the electrical panel area on the east side of the home has broken stucco, and the kitchen pantry is missing 1 door, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/19/2024
Plan of Correction
1
2
3
4
Administrator shall submit picture proof that the stucco was repaired and the kitchen pantry door has been installed.
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: 06/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024


LIC809 (FAS) - (06/04)
Page: 3 of 3