197802483-3-16-2023-28-AS-EIRA-CPYSC6-20230316134502

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197802483
Report Date: 03/16/2023
Date Signed: 03/16/2023 01:45:10 PM

Document Has Been Signed on 03/16/2023 01:45 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:	STEWART RESIDENTIAL HOME		FACILITY NUMBER:	197802483
ADMINISTRATOR:	STEWART, MILLIE		FACILITY TYPE:	735
ADDRESS:	1591 SHIRLEY PLACE		TELEPHONE:	(909) 868-6524
CITY:	POMONA	STATE: CA	ZIP CODE:	91767
CAPACITY: 4		CENSUS: 4	DATE:	03/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:35 AM
MET WITH:	Carl Johnson (S-1) and Millie Stewart (S-2)		TIME COMPLETED:	02:00 PM

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) Elizabeth Irra conducted the required annual inspection. LPA was allowed entry by Carl Johnson/S-1. LPA explained the purpose of today's visit. Millie Stewart/Facility Administrator/S-2 arrived at approximately 9:15 A.M... The facility is licensed for (4) ambulatory clients ages 18 through 59. The fire clearance is approved for (4) ambulatory clients. All clients residing at this home receive case management services provided by San Gabriel Pomona Regional Center. 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 wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has sufficient PPE supplies, has an Infection Control Plan and Mitigation Plan. Facility has COVID-19 signage posted throughout the facility. Bathrooms have hand washing signs, soap and paper towels. Staff are adhering to infection control requirements. Operational Requirements: The fire clearance is approved for (4) ambulatory clients. Last Fire Drill and Earthquake Drill were conducted on 03/01/23. Staff are adhering to operational requirements. Refer to LIC 809C for the continuation of this report.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

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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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: STEWART RESIDENTIAL HOME	FACILITY NUMBER: 197802483
	VISIT DATE: 03/16/2023

NARRATIVE

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Physical Plant & Environment Safety: This facility consists of (3) bedrooms (1) bathroom, living room, den/tv room, kitchen, dining area, laundry area and attached garage. Smoke alarms were tested and operable. Fire extinguisher appeared to be full and was last serviced on 02/01/2023. Carbon monoxide tested and operable. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. There are no firearms or weapons stored at the facility. Hot water supply measured 115.7* in the kitchen and 113.7* in the bathroom.

Staffing: There is sufficient staffing at the facility. Administrator Certificate for Millie Stewart expires on 07/27/2023 and HIV Training Certificate is dated 03/16/2022. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for S-1, Facility Administrator/S-2, S-3, S-4 and S-5. Staff have sufficient on-going training. Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting, Client Rights and Zero Tolerance.

Client Rights-Information: Client personal rights are posted. Per Facility Administrator, there is a main computer to share on premises. (3) out of (4) clients have tablets. (1) out of (4) clients has a cell phone and computer. Internet services are provided and paid for by the Facility Administrator.

Client Records-Incident Reports: LPA reviewed Client files for C-1 through C-4. Client files are maintained at the facility. Admission Agreement, Functional Capability Assessment, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment, Individual Program Plan (IPP), Behavioral Reports, Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights observed.

Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The food is properly stored in the refrigerator (clean and well-maintained). Per S-2, (1) out of (4) clients has a on pureed diet. Pesticides and cleaning supplies are kept away from the food preparation areas (locked inside the laundry closet). Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly. Refer to LIC 809C for the continuation of this report.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

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: STEWART RESIDENTIAL HOME	FACILITY NUMBER: 197802483
	VISIT DATE: 03/16/2023

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Health Related Services The medications are centrally stored and in their original containers. Medications are bubbled packed. LPA reviewed medication for C-1 through C-4 The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician.

Incidental Medical Services: Per S-2, there are no clients at this home with incidental medical services nor have a restricted health condition.

Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan (LIC 610D).

Emergency Intervention : Not-Applicable.
No deficiencies noted..

Note: LPA was experiencing technical difficulties during this visit.

Exit interview, appeals rights and a copy of this report was provided to Millie Stewart

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

LIC809 (FAS) - (06/04)

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