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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802312
Report Date: 09/30/2023
Date Signed: 09/30/2023 01:19:27 PM

Document Has Been Signed on 09/30/2023 01:19 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:HAYLAND GUEST HOMEFACILITY NUMBER:
197802312
ADMINISTRATOR:DE VERA, PERSIVERANDAFACILITY TYPE:
735
ADDRESS:16425 E. HAYLAND ST.TELEPHONE:
(626) 961-4039
CITY:VALINDASTATE: CAZIP CODE:
91744
CAPACITY: 6CENSUS: 5DATE:
09/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:16 AM
MET WITH:TIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Justin Paul De Vera (back up Staff) and explained the purpose of today’s visit. The facility is licensed to serve 6 Ambulatory (only) Mentally Disabled adults ages 18 to 59 years old.

The facility is a single-story home located in a residential area. A tour of the facility includes: Living room, dining room, kitchen, 3 client bedrooms, 2 staff bedrooms, 2 bathrooms, front yard/back yard, covered patio and an attached garage/laundry.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies. There is not an Infection Control Plan on file, details will be documented on 809D.
Physical Plant & Environment Safety: Bathrooms are clean and operational. Clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available and stored in a hall closet. The hot water temperature was tested and measured within the required range of 105-120 degrees. All storage areas for cleaning solutions, toxins, knives, and hazardous items are stored in a secured/locked area and inaccessible to clients. The last Fire/Emergency Drill was conducted on 7/1/2023. Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguisher was observed and is fully charged.
Operational Requirements: The facility has an approved fire clearance and outdoor activity area that is shaded and furnished for outdoor use. (Continued on 809C)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2023
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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Document Has Been Signed on 09/30/2023 01:19 PM - It Cannot Be Edited


Created By: Tena Herrera On 09/30/2023 at 12:23 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: HAYLAND GUEST HOME
FACILITY NUMBER: 197802312

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as the facility did not have an Infection Control Plan on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2023
Plan of Correction
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Licensee will develop an Infection Control Plan and submit plan to LPA for approval by POC due date, via email.
Type B
Section Cited
CCR
80065(f)(4)
Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance. (4) Assistance with prescribed medications which are self-administered.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as 1 staff that assists with administering medication has not completed proper training to assist with prescribed medications which are self-administered which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2023
Plan of Correction
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Licensee will ensure that staff Ferdinand De Vera is provided necessary training to assist clients with prescribed medications which are self-administered by POC due date, and will ensure that this training stay documented in personnel file. Proof of training will be emailed to LPA by POC due date.
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:David Sicairos
LICENSING EVALUATOR NAME:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/30/2023 01:19 PM - It Cannot Be Edited


Created By: Tena Herrera On 09/30/2023 at 12:23 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: HAYLAND GUEST HOME
FACILITY NUMBER: 197802312

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80092.1(l)
General Requirements for Restricted Health Conditions
(l) All training shall be documented in the facility personnel files.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as 2 out of 3 staff do not have training documented in the facility personnel files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2023
Plan of Correction
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Licensee to provide LPA proof of training for staff Ferdinand De Vera and Justin Paul De Vera via email by POC due date and ensure that moving forward trainings will be documented in the facility personnel file.
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:David Sicairos
LICENSING EVALUATOR NAME:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2023


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: HAYLAND GUEST HOME
FACILITY NUMBER: 197802312
VISIT DATE: 09/30/2023
NARRATIVE
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Staffing: There appears to be sufficient staffing at all times in the facility. Administrator Persiveranda V De Vera certificate expires 11/14/23 and has already sent in renewal.
Personnel Records-Training: Staff has criminal record clearance and current First Aid training. Staff files are maintained at the facility and kept in a locked cabinet. 1 Staff who assists with medication administration does not have proper training for medication administration, details will be documented on 809D.
Client Rights-Information: Clients are provided with telephone and internet at the facility.
Client Records-Incident Reports: Client files are kept in a secure location and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Service: Medication is properly labeled and are centrally stored in a locked cabinet and are in their original containers. Medication Administration Record had initials of clients receiving medication for evening and next morning dosage when clients had not yet taken medication, LPA informed staff to only sign after medication is consumed by client to avoid confusion and errors, staff stated this was an error as the medication that was initialed and done so because staff had prepped the medication for clients.
Incidental Medical & Dental: All medications for clients are kept locked and inaccessible to other clients. Training for 2 Staff are not documented in the facility personnel files.
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites.
Emergency Intervention: Clients at this facility do not have restraints nor do they require the use de-escalation techniques.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on 809D.

Exit interview held and a copy of the report was provided to Administrator Persiveranda V De Vera.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2023
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