197802685-4-11-2024-28-AS-ALOZ-D48RYS-20240411132648

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197802685
Report Date: 04/11/2024
Date Signed: 04/11/2024 01:26:58 PM

Document Has Been Signed on 04/11/2024 01:26 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:	MONTEREY PARK HOME		FACILITY NUMBER:	197802685
ADMINISTRATOR/ DIRECTOR:	JENNIFER PICHINTE		FACILITY TYPE:	735
ADDRESS:	1539 FELIZ ST		TELEPHONE:	(626) 289-8701
CITY:	MONTEREY PARK	STATE: CA	ZIP CODE:	91754
CAPACITY: 6		CENSUS: 6	DATE:	04/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:18 AM
MET WITH:	Owen Masayon< Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:47 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) Alberto Lopez conducted an unannounced visit at the facility for the purpose of conducting the required annual inspection. LPA utilized the Compliance and Regulatory Enforcement (CARE) Tool to evaluate the facility. LPA Lopez met with Administrator Hiram C. Owen Masayon. LPA explained the purpose of the visit. The facility is licensed to serve 6 ambulatory and developmentally disabled clients aged 18 to 59. Currently, there are six (6) clients in placement. Three clients are over 60 years of age. 6 Clients are provided Case Management services by East Los Angeles Regional center. Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves. while assisting clients. Staff are disinfecting often for high touched surfaces. Facility has sufficient PPE supplies, has an Infection Control Plan and Mitigation Plan. Bathrooms have hand washing signs, soap and paper towels are available. Per Facility Administrator all staff also have the COVID-19 vaccines including boosters. Facility Administrator is adhering to infection control requirements. Operational Requirements: Fire Drills are conducted every month; the last fire drill was conducted on 4/08/2024 Emergency Disaster/ Earthquake Drills are conducted every three months and the last one was conducted on 01/22/2024. LIC 809C for continuation of report.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 6

Document Has Been Signed on 04/11/2024 01:26 PM - It Cannot Be Edited

Created By: Alberto Lopez On 04/11/2024 at 12:59 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: MONTEREY PARK HOME	FACILITY NUMBER: 197802685
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1565(a)(6)

Other Provisions

(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (6) The location of utility shutoff valves and instructions for use. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above. Facility staff lacks training in emergency and disaster plan which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/25/2024
	Plan of Correction
1 2 3 4	Administrator will train all staff in emergency preparedness and the location of utility shutoff valves and instructions for use, update emergency and disaster plan and send signed roster of participants of training and updated emergency disaster plan to LPA by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Alberto Lopez

LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

LIC809 (FAS) - (06/04)

Page: 2 of 6

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: MONTEREY PARK HOME	FACILITY NUMBER: 197802685
	VISIT DATE: 04/11/2024

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
26
27
28
29
30
31
32

Physical Plant & Environment Safety:

The facility is a two- story home located on a residential street. The facility consists of living room, one staff office, , kitchen, dining room, 4 client bedrooms, 2 shared, 2 client bathrooms, attached garage, and enclosed backyard. and indoor/outdoor activity areas. LPA observed appropriate furniture, lighting fixtures, personal storage space as required, Beds have adequate amount of linen and mattresses, and box springs are in good repair. Bathrooms were found to be within Title 22 regulations. Toilets and water faucets worked properly. Bathroom sinks and showers were free of mold/mildew. LPA observed that sufficient toiletries accessible to clients. Water temperature measured between 113.3- 114.2F which is within range of 105.0 – 120 Degrees F. LPA observed the facility to be clean and appropriately furnished with clear passageways inside and outside. First aid kit is fully stocked with manual, smoke alarms and carbon monoxide detectors were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to clients. Fire extinguisher(s) are fully charged. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. Exits were marked with signs. Notifications and postings were observed which included personal rights, visitor policy, complaint procedures, menu, and emergency disaster plan.

Staffing: There is sufficient staffing at the facility. Staff employed are over the age of 18, are fingerprint and cleared and associated to the facility.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator, and S1-S3. Staff have current CPR/first aid training and sufficient on-going training that meets the annual requirement. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting. Administrator Certificate expires 04/24/2025.

Client Rights-Information: Client personal rights and House Rules are posted. Per Facility Administrator, facility provides wi-fi services for facility clients.

Client Records-Incident Reports: LPA reviewed Client files for C1 through C6. Client files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Appraisal Needs and Services Plan, Functional Capabilities Assessment, Mental Health Intake Assessment, Client Cash Resources. Special Incident Reports, Client Personal Property and Clients Personal Rights.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

LIC809 (FAS) - (06/04)

Page: 5 of 6

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: MONTEREY PARK HOME	FACILITY NUMBER: 197802685
	VISIT DATE: 04/11/2024

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
26
27
28
29
30
31
32

Food Service: The facility has sufficient food supplies of 2-day perishable and 7 day supply of non-perishable items. The food is properly stored in the refrigerator which is clean and well-maintained. There are no clients with special diets residing at this facility. Kitchen is kept clean and free from rodents and other bugs/ insects. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services: The medications are centrally stored and in their original containers. LPA reviewed medication for 4 clients. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubble packed and delivered monthly.

Incidental Medical Services: Per Facility Administrator, there are no clients at this home with incidental medical services or restricted health condition.

Disaster Preparedness: The facility has an Emergency Disaster Plan but needs to be updated after staff is trained.

Emergency Intervention: Not Applicable.

Deficiency noted. Technique advisories provided. Exit interview and a copy of this report, 809D and appeal rights was provided.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

LIC809 (FAS) - (06/04)

Page: 6 of 6