197802585-2-9-2024-28-AS-CWOG-D2AUBR-20240209142647

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197802585
Report Date: 02/09/2024
Date Signed: 02/09/2024 02:27:49 PM

Document Has Been Signed on 02/09/2024 02:27 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:	EL ESPEJO HOME		FACILITY NUMBER:	197802585
ADMINISTRATOR:	MARIA MADRIGAL		FACILITY TYPE:	735
ADDRESS:	13823 EL ESPEJO ROAD		TELEPHONE:	(562) 941-5674
CITY:	LA MIRADA	STATE: CA	ZIP CODE:	90638
CAPACITY: 6		CENSUS: 6	DATE:	02/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:10 AM
MET WITH:	Michelle Puno		TIME COMPLETED:	02:50 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) Christine Wong conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Administrator Michelle Gozon Puno and explained the reason of the visit and also assisted LPA with the visit. The facility is approved for serve Developmentally Disabled Adults AGE RANGE 18 THROUGH 59. Ambulatory only. The facility is vendored by East Los Angeles Regional Center. The following twelve (12) tool domains were observed and reviewed: Infection Control, Physical Plant/Environmental Safety, Operational Requirements, Staffing, Personal Records-Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incidental Medical Services, Disaster Preparedness and Emergency Intervention. 1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility still encourages hand washing and temperature check for clients and staff. The facility has an Infection Control Plan and COVID-19 mitigation plan in place. 2. Physical Plant and Environmental: The facility is a single story house and located in a residential neighborhood area, The facility includes: Living room, dining area, kitchen, four clients bedrooms, two clients bathrooms, staff break room, storage room and a detached garage. Bedroom#1 and #2 has one bed, one chair, one night stand, one drawer, required beddings and furniture and sufficient lighting and closet space. Bedroom#3 and #4 has two beds, two night stands, two drawers, required beddings and furniture and sufficient lighting and closet space. The two client bathrooms are clean, sanitary and in a good working condition. The hot water temperature in both clients bathrooms were tested between 108.3 and 113.9 degrees F. All the appliances in the kitchen are working properly.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: EL ESPEJO HOME	FACILITY NUMBER: 197802585
	VISIT DATE: 02/09/2024

NARRATIVE

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The knives are locked and stored in the kitchen drawer next to the oven. The cleaning supplies are stored and locked under the sink. LPA inspected the carbon monoxide detector and it's working well. The extra personal hygiene products are stored in the first bathroom and storage room in the backyard. The facility usually turn on the hallway light for the client to use the non-private bathrooms during the night time. The facility has a telephone on the premises.

3. Operational Requirements: The facility is approved for ambulatory clients only. Currently all clients are ambulatory in the facility. The facility has a covered patio with table and chairs for client to utilized for outdoor activity. The facility would also let client to attend community activities if there's an opportunity or if client wanted.

4. Staffing: Facility has a sufficient staffing in the facility LPA also reviewed the night shift staff and the staff has the updated training for the facility planned emergency procedure.

5. Personnel Records-Training: LPA reviewed three (3) staff files in the facility and they do have the required documents in their personnel files which includes updated required training hours, first aid certificate, health screening and TB test result. The facility administrator is Michelle Puno and her administrator certificate will expire on 4/2/25 and also has the required HIV and TB training certificate in file. All the staff are over 18 years old, criminal background check cleared and associated with the facility.

6. Client's Right-Information : Currently the facility has no client required postural support. The facility does serve adults has internet service shall provide at least one access device.

7. Food Service: The facility has sufficient food supply include minimum two days perishable and seven days non perishable. All the food are stored probably. No clients in the facility is required modified diet. The refrigerator is also maintained within the required temperature.

8. Client records-incident reports: LPA inspected all six (6) clients files in the facility and all clients files are stored in the cabinet next to the dining table. All clients files have the required documents which included face sheet, functional capacity assessment, admission agreement, Individual Program Plan (IPP), updated physician report, TB test result, ambulatory status and medication list.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024

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: EL ESPEJO HOME	FACILITY NUMBER: 197802585
	VISIT DATE: 02/09/2024

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9. Health Related Services: The facility medication is centrally stored and locked in the cabinet next to the dining area. LPA inspected all six (6) clients medication and all seemed to be accurate and up-to-dated. All six (6) clients have sufficient 30 days supply of medication.

10. Incidental Medical Services: Currently no client in the facility is on any restricted health condition plan and no client is with prohibited health condition retained in the facility.

11. Disaster Preparedness: The facility has an updated Emergency Disaster Plan (LIC 610D) in place. The facility conducted fire and earthquake drill monthly. The facility has two alternative shelter location. The staff also trained annually for the emergency disaster plan.

12. Emergency Intervention: The facility does not use any restraints on clients as the facility is a Level 3 home.

No deficiencies were observed during the visit.

Exit Interview conducted. A copy of the report was provided to Administrator Michelle Puno

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024

LIC809 (FAS) - (06/04)

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