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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802312
Report Date: 09/09/2024
Date Signed: 09/09/2024 03:09:32 PM

Document Has Been Signed on 09/09/2024 03:09 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:HAYLAND GUEST HOMEFACILITY NUMBER:
197802312
ADMINISTRATOR/
DIRECTOR:		DE VERA, PERSIVERANDAFACILITY TYPE:
735
ADDRESS:16425 E. HAYLAND ST.TELEPHONE:
(626) 961-4039
CITY:VALINDASTATE: CAZIP CODE:
91744
CAPACITY: 6CENSUS: 4DATE:
09/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:35 PM
MET WITH:Administrator Persiveranda De Vera TIME VISIT/
INSPECTION COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Administrator Persiveranda De Vera and the purpose of the visit was discussed. The facility is licensed for 6 ambulatory adults, ages 18 through 59.

The following 12 (CARE) tool domains were utilized during the inspection:

Infection Control: Staff are using appropriate hand hygiene and wearing gloves when deemed necessary. Facility has an Infection Control Plan in place. LPA collected a copy

Operational Requirements: Facility is licensed to serve, and has fire clearance for, six (6) ambulatory clients. Staff are adhering to operational requirements.

Physical Plant & Environment Safety: 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 observed sufficient space in the outdoor areas for clients use. There are no pools or bodies of water on the premises. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. There are no firearms or weapons stored at the facility. Water temperature measured within Title 22 regulations of 105-120 degrees.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed three (3) staff files and they have current First Aid/CPR certification. Staff have their Health Screening, fingerprint clearance, and criminal record statements on file. Staff training's reviewed. Administrators file was reviewed.

Continued on 809-C page
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2024
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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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: HAYLAND GUEST HOME
FACILITY NUMBER: 197802312
VISIT DATE: 09/09/2024
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Staffing: There is sufficient staffing at the facility. Administrator Certificate for Persiveranda is current. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Client Rights-Information: Clients are informed of their personal rights. Internet service is provided to clients. Clients have personal items for internet use.

Client Records-Incident Reports: LPA reviewed all four (4) Client files, maintained at the facility. They have the required documentation such as Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent forms, Individual Program Plan/IPP, Client Rights, Property Valuable and Cash resources forms.

Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. There are no clients on special diets. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services: The medications are centrally stored. LPA reviewed medications for all four (4) Clients. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician.

Incidental Medical Services: There are (0) clients with restricted health condition plan. (0) Clients with prohibited health condition. Postural supports currently not being used.

Disaster Preparedness: The facility has the current Emergency Disaster Plan in place. Last emergency drill was conducted on 7/1/24.

Emergency Intervention: Manual restraints are not used.

Per California Code of Regulations, Title 22, NO deficiencies were cited. Exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024
LIC809 (FAS) - (06/04)
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