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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803031
Report Date: 02/29/2024
Date Signed: 02/29/2024 04:31:08 PM

Document Has Been Signed on 02/29/2024 04:31 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:TRI-STAR HOMESFACILITY NUMBER:
197803031
ADMINISTRATOR:DARWIN BELMONTEFACILITY TYPE:
735
ADDRESS:2266 RALEO AVENUETELEPHONE:
(626) 269-0241
CITY:ROWLAND HEIGHTSSTATE: CAZIP CODE:
91748
CAPACITY: 6CENSUS: 6DATE:
02/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:21 PM
MET WITH:Darwin BelmonteTIME COMPLETED:
04:50 PM
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Licensing Program Analysts (LPA) Christine Wong and Daniel Konishi conducted the unannounced Annual Inspection and met with Caregiver Anita Russell who allowed the entry of the facility and explained the reason of today's visit and shortly after, the administrator Darwin Belmonte arrived and assisted with the visit. LPAs will be using the Compliance And Regulatory Enforcement (CARE) Tools to inspect the facility. The facility is licensed to serve six (6) mentally disabled ambulatory only ages 18-59.

The following domains were reviewed during today's annual required visit which included: infection control, physical plant and environmental, operational requirements, staffing, personnel 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: The facility staff would encourage client to practice hand washing. The facility staff would wear gloves and masks at the facility and facility staff would disinfect the facility more than once daily.

2. Physical Plant and Environmental Safety: The facility is a single story house and located in a residential neighborhood area. The facility includes: living room, dining area, kitchen, three clients bedrooms, one client bathroom, live in staff room and an attached garage. Each client room has two beds, dressers, required furniture and beddings and sufficient lighting and closet space. The client bathrooms is clean, sanitary and in a good working condition. The hot water temperature in the client bathroom was tested at 116 degrees F. which is within the Title 22 regulation. The kitchen appliances are working properly. The sharp knives are stored and locked in the cabinet in the garage. The cleaning supplies are stored and locked in the cabinet in the garage. The extra personal hygiene products are stored in the cabinet in the garage. There's a night light plug in the hallway, so client can have access to the non-private bathrooms at night. The facility has a telephone service on the premises. The carbon monoxide detectors in the facility are working well.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/29/2024
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: TRI-STAR HOMES
FACILITY NUMBER: 197803031
VISIT DATE: 02/29/2024
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3. Operational Requirements: All the clients are ambulatory and they are within the fire inspection limit. The facility would support the client to participate community activities if there's a chance or an opportunity. The facility has a shaded area with table and chairs for client to utilize the outdoor activity. The facility does fire drill/earthquake drill in the facility but no documentation shown that.

4. Staffing: The facility has a sufficient staffing in the facility. All the staff in the facility are over 18 years old,background check cleared and associated with the facility.

5. Personal Records/Training: The staff files are stored in the file cabinet near the entrance door. LPA inspected all three staff files and they have the required documents in files: health screening and TB test result, first aid certificate. The facility administrator is Darwin Belmonte and the administrator certificate expiration date: 7/30/2024. The administrator does not have an updated HIV and TB training certificate.

6. Client's right: No client in the facility required any postural support. The facility has provide internet service with at least one access device.

7. Food Service: The facility provides three meals a day to client. No client in the facility has a modified diet. The facility has ample supply of 2 days perishable and 7 days non-perishable food supply in the facility. The food are stored properly.

8. Client Records-Incident Reports: All the client files are stored in the file cabinet near the entrance door. LPA inspected all six clients files and they all have the required documents included face sheet, admission agreement, functional capacity assessment, updated physician report, Needs and service plan, medication list and ambulatory status.

9. Health Related Services: All the client's medication are centrally stored and locked in the medication cart. LPA inspected all six client's medication and they are all accurate and updated. All client's have sufficient 30 days supply of medication.

10. Incidental Medical Services: No client in the facility has any restricted health condition or prohibited health condition or required monitor closely.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
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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: TRI-STAR HOMES
FACILITY NUMBER: 197803031
VISIT DATE: 02/29/2024
NARRATIVE
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11. Disaster Preparedness: The facility does not have an updated Emergency Disaster Plan. The facility has two alternative temporary shelter location.

12. Emergency intervention: Facility does not use any restraints on clients.

A deficiency is being cited under the California Code of Regulations Title 22 Division 6 Chapter 8 and will be noted on 809-D page.

An exit interview is conducted, copy of the report and appeal rights given was provided to the administrator.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/29/2024 04:31 PM - It Cannot Be Edited


Created By: Christine Wong On 02/29/2024 at 03:48 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: TRI-STAR HOMES
FACILITY NUMBER: 197803031

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80020(c)

80020 Fire Clearance (c) A licensee of an Adult Residential Facility or Group Home utilizing secured perimeters shall conduct fire and earthquake drills pursuant to Health and Safety Code section 1531.15(h).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the documents reviewed, the facility does not have a fire/earthquake drill log in the facility which posed on a potential risk.
POC Due Date: 03/07/2024
Plan of Correction
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The administrator will conduct the fire/earthquake drill log with clients in the facility and send to LPA by POC due date.
Type B
Section Cited
CCR
85065.6(b)(1)
85065.6 Night Supervision
(b) Employees providing night supervision from 10:00 p.m. to 7:00 a.m., as specified in (c) through (f) below, shall be available to assist in the care and supervision of clients in the event of an emergency, and shall have received training in the following:

(1) The facility's planned emergency procedures.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the record review, LPA observed the night shift staff does not have any facility planned emergency procedure trianing.
POC Due Date: 03/07/2024
Plan of Correction
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The administrator will send the NOC shift training log (Facility planned emergency procedure) to LPA by POC due date.
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:David Sicairos
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 02/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/29/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/29/2024 04:31 PM - It Cannot Be Edited


Created By: Christine Wong On 02/29/2024 at 03:55 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: TRI-STAR HOMES
FACILITY NUMBER: 197803031

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(k)
85064 Administrator Qualifications and Duties:

(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on documents reviewed, LPA did not observe the administrator received the HIV and TB training which posed a potential risk in the facility.
POC Due Date: 03/14/2024
Plan of Correction
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The administrator will send the updated HIV and TB Training certificate by POC due date.
Type B
Section Cited
HSC
1565(d)
1565 Emergency Disaster Plan

(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee, administrator, or regulated individual shall sign and date the documentation to indicate that the plan has been reviewed and updated as necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA observed the emergency disaster plan is not updated and it's dated back in 2016 which posed a potential risk in the facility.
POC Due Date: 03/07/2024
Plan of Correction
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The administrator will send the updated Emergency Disaster plan (LIC610D) by POC due date.
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:David Sicairos
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 02/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/29/2024


LIC809 (FAS) - (06/04)
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