197802778-7-9-2024-28-AS-NGAA-D6ZVH4-20240709162631

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197802778
Report Date: 07/09/2024
Date Signed: 07/09/2024 04:26:37 PM

Document Has Been Signed on 07/09/2024 04:26 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	ELLETT RESIDENTIAL FACILITY		FACILITY NUMBER:	197802778
ADMINISTRATOR/ DIRECTOR:	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:	07/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:05 PM
MET WITH:	Lester Ellet, Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Noemi Galarza made an unannounced annual inspection visit. The purpose of the visit was explained to Administrator Lester Ellet. The facility serves developmentally disabled residents under age 59. The facility is licensed as a level 3 Adult Residential Facility (ARF) vendored by Eastern Los Angeles Regional Center. 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 following 12 (CARE) tool domains were utilized during the inspection.

Infection Control: The facility staff are using appropriate hand hygiene cleaning and disinfecting the home. An Infection Control Plan was reviewed.

Physical Plant/Environment Safety: 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 were tested and are operation. The facility has two (2) fully charged fire extinguishers. Hot water temperature readings measured between the required 105 - 120 degrees Fahrenheit. Storage areas for cleaning solutions/toxins, knives, and hazardous items were inaccessible to clients.

Operational Requirements: Fire clearance is approved for four (4) ambulatory only residents. Care and supervision to meet the clients needs was observed. No special equipment and supplies are used by clients. Facility manages residents P & I monies. The Surety Bond expires 8/31/2024.

Staffing: A total of 3 staff members provide care and supervision to the clients.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

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

FACILITY NAME: ELLETT RESIDENTIAL FACILITY	FACILITY NUMBER: 197802778
	VISIT DATE: 07/09/2024

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Personnel Records/Staff Training: Threee (3) staff files were reviewed and contained criminal background clearance, in-service training, 1st Aid/CPR training, and health screening. Administrator certificate expires 3/24/2025.

Resident Rights/Information: Resident Personal Rights poster is posted in the dining area. Internet access is available for residents. Physician's orders are on file. The resident does not have a modified diet order.

Resident Records/Incident Reports: One (1) resident files were reviewed containing admission agreements, Physician's Reports, IPPs, medical/functional assessments, Behavior Reports, TB clearance, personal rights, medical consent, medication 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.

Health Related Services: Residents are assisted with self administration of prescription and non-prescription medications. Medications records were reviewed. Centrally stored medications are kept in a safe and locked place not accessible to clients in care. Medications are given according to Physician directions. 30-Day supply of medications were observed.

Incident Medical and Dental: All residents have a Needs and Services Plan and updated medical assessments.

Disaster Preparedness, and Emergency Intervention: LIC 610D form "Emergency Disaster Plan/Disaster and Mass Casualty Plan has not been updated.

The last Fire/Emergency Drill was conducted on 6/15/2024.

Emergency Intervention: No manual restraints, seclusion, or de-escalation techniques are used.

Per Title 22 one deficiency was cited.

Exit interview was conducted with Lester Ellet. A copy of the report and appeal rights were issued.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/09/2024 04:26 PM - It Cannot Be Edited

Created By: Noemi Galarza On 07/09/2024 at 03:57 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: 07/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80023(a)

Disaster & Mass Casualty Plan

(a) Each licensee shall have and maintain on file a current, written disaster and mass casualty plan of action. 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 the LIC 610D Emergency and Disaster Plan form is not updated, which poses a potential health, safety, or personal rights risk to persons in care.
	POC Due Date: 07/23/2024
	Plan of Correction
1 2 3 4	Administrator agreed to submit a copy of the updated LIC 610D Emergency and Disaster Plan. Facility shall maintain the form on file at the facility.

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:

Noemi Galarza

LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

LIC809 (FAS) - (06/04)

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