197802778-7-6-2023-28-AS-NGAA-CTGVFH-20230706162357

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197802778
Report Date: 07/06/2023
Date Signed: 07/06/2023 04:24:06 PM

Document Has Been Signed on 07/06/2023 04:24 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:	ELLETT RESIDENTIAL FACILITY		FACILITY NUMBER:	197802778
ADMINISTRATOR:	ELLETT, LESTER WAYNE		FACILITY TYPE:	735
ADDRESS:	8242 CATALINA AVENUE		TELEPHONE:	(562) 789-0545
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90602
CAPACITY: 4		CENSUS: 1	DATE:	07/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:43 PM
MET WITH:	Lester Ellet, Administrator		TIME COMPLETED:	04:30 PM

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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to Administrator Lester Ellet. There is one (1) ambulatory developmentally disabled resident under age 59. The facility is licensed as a level 3 Adult Residential Facility (ARF) vendored by Eastern Los Angeles Regional Center.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention.

Infection Control:

Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility is encouraging hand washing and self symptom check of staff and visitors. Each resident bedroom is designated as a COVID-19 isolation room if needed. The facility does not have an Infection Control Plan.

Physical Plant/Environment Safety:

The facility is a single story home licensed for 4 ambulatory clients located in a residential neighborhood. It consists of 3 client bedrooms, 1 staff bedroom, 3 bathrooms, dining room, kitchen, living room, den, outdoor patio and detached garage.
The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors are operational. The facility has two (2) fully charged fire extinguishers. Cleaning supplies and toxic substances are inaccessible to clients.
Water temperature readings measured between the required 105 - 120 degrees Fahrenheit.

See next page

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ELLETT RESIDENTIAL FACILITY	FACILITY NUMBER: 197802778
	VISIT DATE: 07/06/2023

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Health Related Services:

Resident is assisted with self administration of prescription and non-prescription medications.
One (1) centrally stored resident medication record was reviewed. Centrally stored medications are kept in a safe and locked place not accessible to resident in care. Medications are given according to Physician directions. 30-Day supply of medications were observed.

Incident Medical and Dental:

Resident has a Needs and Services Plan and COVID-19 vaccination cards on file.
Staff training was on file.

Disaster Preparedness, and Emergency Intervention:

A posted Emergency Disaster Plan LIC 610D containing emergency evacuation information was observed.
An emergency drill was conducted on 6/1/2023.

Emergency Intervention:

No manual restraints or seclusion are used with clients in care.

Per California Code of Regulations, Title 22, a deficiency was cited.

Exit interview conducted with Administrator Nicole Collar. A copy of the report and appeal rights were issued.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ELLETT RESIDENTIAL FACILITY	FACILITY NUMBER: 197802778
	VISIT DATE: 07/06/2023

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Operational Requirements:

Fire clearance was approved for four (4) ambulatory residents.
Care and supervision to meet the clients needs was observed. No special equipment and supplies are used by clients.
Current Surety bond was reviewed and is current.

Staffing:

A total of three (3) staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

Administrator certificate expired 3/24/23. Documents were submitted to recertification unit. Certificate has not been received.
Three (3) staff files were reviewed for criminal background clearance and training.
Personnel records have health/TB screenings, CPI training, certifications, and 1st Aid/CPR training.

Client Rights/Information:

Physician orders and personal rights were reviewed in resident file.

Client Records/Incident Reports:

One (1) resident file was reviewed containing admission agreement, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, IPP reports, personal rights, medical consent, nutritional assessments, medication administration records, and P & I records.

Food Service:

The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.
No physician orders for modified diets are in place.

See next page.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/06/2023 04:24 PM - It Cannot Be Edited

Created By: Noemi Galarza On 07/06/2023 at 04:02 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: ELLETT RESIDENTIAL FACILITY	FACILITY NUMBER: 197802778
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85095.5(c)(1)(A-F)

INFECTION CONTROL REQUIREMENTS. An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. The Infection Control Plan shall include all of the following: Identification of a staff position to perform the duties of an Infection Preventionist for the facility. (B) A description of how the licensee shall meet the specific infection control practice requirements of subsections (a), (b) and (d). An Infection Control Training Plan. The licensee shall review the use of infection control procedures in the facility at least annually, if local government public health determines an epidemic outbreak has occurred, or if the review is requested by the local licensing agency. The licensee shall ensure that staff encourage clients to follow infection control practices as necessary. Staff shall demonstrate knowledge of and skill in infection control, as appropriate to the job assigned and as evidenced by safe and effective job performance.This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in that an infection control plan was not submitted to CCL as required; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/13/2023
	Plan of Correction
1 2 3 4	Administrator agreed to develop and submit a copy of the Infection Control Plan.

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:

Noemi Galarza

LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

LIC809 (FAS) - (06/04)

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