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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802315
Report Date: 09/23/2023
Date Signed: 09/23/2023 01:37:48 PM

Document Has Been Signed on 09/23/2023 01:37 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: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:
09/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH:Sadie Gonzalez - Care Provider/VolunteerTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Aura Lauretta (Licensee) and explained the purpose of today’s visit. The facility is licensed to serve 4 developmentally 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 area, kitchen, den, laundry area, 2 client bedrooms, 1 staff bedroom, 1 client bathroom, 1 staff bathroom, detached garage, front yard, backyard and 2 locked tool sheds.

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 while assisting clients’ medications. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan.


Physical Plant & Environment Safety: LPA toured the facility and the following was observed: 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 to clients in care. The hot water temperature was tested in client bathroom; the sink did not produce hot water and was below the required range of 105-120 degrees F, the shower water temperature measured 133.5 degrees F which is outside of the required range, details will be cited on the 809-D. All storage areas for cleaning solutions, toxins, knives, and hazardous items are stored in a secured/locked area and inaccessible to clients. Smoke detectors and carbon monoxide detectors are operable and in compliance.
Operational Requirements: The facility has a Plan of Operation on file and conduct their fire/earthquake drills quarterly with the last drill conducted on 7/20/23.
(Continued on 809-C)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 09/23/2023 01:37 PM - It Cannot Be Edited


Created By: Tena Herrera On 09/23/2023 at 12:41 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: 09/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, 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 as LPA tested water in sink and reading was 78.8 degrees F which is below the required range, LPA then tested the water in the shower and water measured at 133.5 degrees F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2023
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 9/29/23 via email. Documentation will be a water temperature log with date, time and teperature reading (which shall be within the required range), this log must be for the next 5 consecutive dates beginning 9/24/23 ending 9/28/29.
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: 09/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2023


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Document Has Been Signed on 09/23/2023 01:37 PM - It Cannot Be Edited


Created By: Tena Herrera On 09/23/2023 at 12:50 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: 09/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(e)

(e) All personnel records shall be maintained at the facility site and shall be available to the licensing agency for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on, LPA observation and attempted file review, the licensee did not comply with the section cited above as staff files were not readily accessible/available during visit, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2023
Plan of Correction
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Licensee to create plan as to where files will be maintained and what designated staff will have access to such files. Licensee to ensure files have at the following documentation (along with all other required documentation per Title 22 regulations):
-physician report -tb test -criminal background clearance -all required training -valid cpr certificate

Above information including staff information for Sadie Gonzalez must be submitted to LPA by POC due date.
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: 09/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2023


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: VRAM ADULT FAMILY HOME
FACILITY NUMBER: 197802315
VISIT DATE: 09/23/2023
NARRATIVE
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Staffing: There appears to be sufficient staffing at all times in the facility. With at least one staff on site between the hours of 10pm – 7am.
Personnel Records-Training: Staff files were not readily available during today’s visit, details on citation can be found on 809-D. Administrator Vincent Lauretta certificate has expired, however, was able to show proof of pending renewal with CCL receipt date of 5/19/23.
Client Rights-Information: Clients are provided with telephone access at the facility.
Client Records-Incident Reports: Client files are kept in a secure location within a locked cabinet in the dining area 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. During the visit today, LPA reviewed 3 clients’ medication no issues were observed. (one client away with family and family has medication)
Incidental Medical & Dental: There are no clients in care with restricted health conditions nor that require routine care.
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 Sadie Gonzalez.

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

DATE: 09/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2023
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