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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802315
Report Date: 09/20/2022
Date Signed: 09/20/2022 03:32:27 PM

Document Has Been Signed on 09/20/2022 03:32 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:VRAM ADULT FAMILY HOMEFACILITY NUMBER:
197802315
ADMINISTRATOR:LAURETTA, AURAFACILITY TYPE:
735
ADDRESS:2327 HILLVIEW AVE.TELEPHONE:
(323) 721-9618
CITY:MONTEREY PARKSTATE: CAZIP CODE:
91754
CAPACITY: 4CENSUS: 4DATE:
09/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Aura Lauretta, licenseeTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection with the focus of the infection control domain. LPA arrived unannounced and met with licensee, Aura Lauretta. The purpose of the visit was explained. The facility is licensed for 4 ambulatory developmentally disabled adults, ages 18 through 59 years.

LPA Chan toured the facility with licensee and the following were observed:
* Facility has 3 bedrooms and 2 bathrooms in which 2 client bedrooms are shared and 1 designated for the live-in licensee. There is a living room, dining room, family room, kitchen, spacious backyard, and a detached garage.
* Some COVID-19 signage are posted at the facility and in the bathrooms. LPA recommended to add additional signage in the common areas such as cough/sneeze etiquette signs.
* Knives and disinfectants are stored and locked in cabinet by the the laundry area.
* The hot water temperature was measured in the bathroom #2 as 77 degree F and the kitchen sink as 101.7 degree. The sink in bathroom #2 was draining very slowly.
* There are sufficient food supplies of 2 day perishable and a week of non-perishable.
* Medications are stored and locked in a safe located in the dining room. LPA reviewed medications for 2 clients who are currently taking medication. The medications are being administered as prescribed.
* Sufficient PPE supplies are stored at the facility.

LPA provided technical assistance on the following:
* Documentation of daily screening of staff and clients and screening of visitors.

Deficiencies are documented on the LIC809D. An exit interview was conducted. A copy of this report along with the LIC9102 Technical Assistance were given to the licensee.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2022
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 09/20/2022 03:32 PM - It Cannot Be Edited


Created By: Cynthia D Chan On 09/20/2022 at 03:09 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: VRAM ADULT FAMILY HOME
FACILITY NUMBER: 197802315

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
80088 Furniture, Fixtures, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water.
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 for bathroom #2 and the kitchen sink which poses a potential personal rights risk to persons in care.
POC Due Date: 09/26/2022
Plan of Correction
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The licensee shall ensure clients are getting hot water between 105 to 120 degrees F. Documentation of the hot water temperature shall be submitted to LPA by 9/26/22.
Type B
Section Cited
CCR
80087(a)
80087 Buildings 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 where the bathroom #2 sink appeared clogged and the water drained very slowly which poses a potential safety risk to persons in care.
POC Due Date: 09/26/2022
Plan of Correction
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The licensee shall ensure the sink works properly and the water drains. The licensee shall submit documentation of the sink draining properly by due date 9/26/22.
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:Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2022


LIC809 (FAS) - (06/04)
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