197802895-11-18-2024-28-AS-ALOZ-DB5SHH-20241118125333

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197802895
Report Date: 11/18/2024
Date Signed: 11/18/2024 12:53:40 PM

Document Has Been Signed on 11/18/2024 12:53 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:	ROSEMEAD HOME		FACILITY NUMBER:	197802895
ADMINISTRATOR/ DIRECTOR:	GUI-QIN ZONG		FACILITY TYPE:	735
ADDRESS:	3132 ROSEMEAD PLACE		TELEPHONE:	(626) 288-9346
CITY:	ROSEMEAD	STATE: CA	ZIP CODE:	91770
CAPACITY: 6		CENSUS: 3	DATE:	11/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:10 AM
MET WITH:	Guoliang Li, Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:59 PM

NARRATIVE

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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Xiapcui Wang DSP and Administrator Guoliang Li arrived a short time later and LPA explained the reason of the visit. The facility is approved for serve Developmentally Disabled Adults, six (6) ambulatory clients. The facility is licensed as a level 3 home vendored by East Los Angeles Regional Center.

Facility is licensed to served 6 adults between the ages of 18-59 years old. Currently there are 3 clients residing at facility. One client is over 60 years of age.

The following was observed:

1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. Facility is disinfecting throughout the day.

Physical Plant & Environment Safety: The facility is free of debris. There are no security bars or weapons on the premises. The hot water temperature was tested, and temperature measured between 113.3 -116.9 degrees F which is within required range. All storage areas for cleaning solutions, toxins, knives, and hazardous items are inaccessible to clients. The last Fire/Emergency Drill was 05/10/24. Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguishers were observed operational. Carpet is unclean and loose at intervals that make it a safety hazard.

3. Operational Requirement: The facility is licensed for six (6) ambulatory clients, 3 non-ambulatory and currently all three (3) clients are ambulatory. The last fire/earthquake drill was conducted on 05/10/24. Clients can attend the community events/activities if there's an opportunity and chance. The facility has a shaded area with table and chairs for client to utilize the outdoor activity. (Continued on 809C)

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024

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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Document Has Been Signed on 11/18/2024 12:53 PM - It Cannot Be Edited

Created By: Alberto Lopez On 11/18/2024 at 12:28 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: ROSEMEAD HOME	FACILITY NUMBER: 197802895
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. Carpet is uncleaned and loose is some areas which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/02/2024
	Plan of Correction
1 2 3 4	Administrator will clean, repair or replace carpet and send proof to LPA by POC date which is 12/02/2024.

Type B

Section Cited

HSC

1565(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill. 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. Last fire drill was 05/10/204 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/19/2024
	Plan of Correction
1 2 3 4	Administrator will conduct fire drill for all staff and send proof of correction by POC to LPA.

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: 11/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024

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: ROSEMEAD HOME	FACILITY NUMBER: 197802895
	VISIT DATE: 11/18/2024

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4) Staffing: A total of two (2) staff members provide care and supervision to the clients.

5. Personnel Records-Training. The facility staff files are at facility. All the staff are over 18 years old and older, fingerprint cleared and associated with the facility. The administrator is Guoliang Li, Administrator and his administrator certificate expiration date is 09/08/24, Administrator sent check for renewal on 06/25/2024 and he has updated HIV and TB training. LPA reviewed four (2) staff files and they all have the required documents including health screening, TB test result, updated first aid certificate and required training hours.

6. Client right-Information: Currently there's no client required postural support. The facility also has internet service and provide at least one internet access device in the facility. Client rights poster is posted by entrance.

7. Client Records/Incident Reports: All three (3) client files were reviewed containing admission agreements, current IPP, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent.

8. 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 during the visit.

9. Health Related Services: Clients are assisted with self-administration of prescription and non-prescription medications. Three (3) centrally stored resident medication records were reviewed Centrally stored medications are kept in a safe and locked area and not accessible to clients in care. Medications are given according to Physician orders.

10. Incident Medical and Dental: Client are assisted with medical and dental services.

11. Disaster Preparedness: The facility has an updated Emergency Disaster Plan posted at facility.

12. Emergency Intervention: No manual restraints or seclusion are used with clients in care.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during the visit. Technical Advisory provided. Exit interview held and a copy of the report along with appeal rights were provided.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024

LIC809 (FAS) - (06/04)

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