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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803338
Report Date: 09/03/2024
Date Signed: 09/03/2024 04:47:57 PM

Document Has Been Signed on 09/03/2024 04:47 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:EXCEL ADULT HOMESFACILITY NUMBER:
197803338
ADMINISTRATOR/
DIRECTOR:		HELAL, SANAAFACILITY TYPE:
735
ADDRESS:133 NORTH EL MOLINOTELEPHONE:
(626) 300-9050
CITY:ALHAMBRASTATE: CAZIP CODE:
91801
CAPACITY: 4CENSUS: 4DATE:
09/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:42 PM
MET WITH:Sanaa Helal, Administrator TIME VISIT/
INSPECTION COMPLETED:
04:58 PM
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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 Staff Freddy Hernandez and explained the reason for the visit. Administrator arrived a short time later and assisted with the visit. The facility is approved to serve Developmentally Disabled Adults, four (4) ambulatory clients ages 18-59. One client is over 60. The facility is licensed as a level 2 home vendored by East Los Angeles Regional Center.

The following twelve (12) tool domains were observed and reviewed:

1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility still encourages hand washing, still checking client temperature twice a day and staff disinfected the facility every shift. The facility has an Infection Control Plan and COVID-19 mitigation plan in place.

2. Physical Environmental and Safety: The facility is a single story house and located on residential neighborhood area. The facility includes living room,dining room, kitchen, activity room, two (2) client bedrooms and 1 staff bathroom, and laundry room. Rooms have required furniture and bedding and sufficient lighting and closet space. The client bathrooms are clean, sanitary and in a good working condition. The hot water in the kitchen sink and laundry room tested between 93.7 – 139.1 degrees F which are not within the Title 22 regulation. There are signs posted warning that water is over 120 degrees in the kitchen and staff bathroom. The appliances in the kitchen are working well. The knives and sharp utensils are stored and locked in a lock box in the kitchen. All the chemicals and cleaning supplies are stored and were locked in in the kitchen and not accessible to client. The extra linen and personal hygiene products are stored in the hallway cabinet/closet. The facility does have a working landline telephone system for client to use. The hallway light is always on during night for client to access the bathrooms. LPA inspected the carbon monoxide detectors, The passageway, walkway and patio are free of obstruction.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 09/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2024
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: EXCEL ADULT HOMES
FACILITY NUMBER: 197803338
VISIT DATE: 09/03/2024
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. Operational Requirement: The facility is licensed for 4 ambulatory clients and currently all four (4) clients are ambulatory. The last fire/earthquake drill was conducted on 07/25//2024. 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 area.

4.Staffing: The facility has sufficient staffing. LPA reviewed the NOC shift staff files, and they have current CPR/FIRST AID certificate. Staff need facility training on how to shut off utilities.

5. Personnel Records-Training. The facility staff files are stored at facility. All the staff are over 18 years old and older, fingerprint cleared and associated with the facility. The administrator is Sanaa Helal, administrator certificate expiration date is 08/24/2024 and applied for renewal on 06/02/2024, has her updated HIV and TB training. LPA reviewed four (4) staff files and they all have health screening TB test result.

6. Client right-Information: Currently there's no client that required postural support. The facility has internet service and provide at least one internet access device in the facility.

7. Client Records- Incident Reports: The client files are stored in the locked file cabinet. All client files have the required documents include face sheet, admission agreement, functional capability assessment, health screening and TB Test, Individual Program Plan (IPP), ambulatory status and medication list. One client is over 60 and needs LIC602 for Residential Care Facility for the Elderly.

8. Food Service: Currently no client is on modified diet. The facility does have two days perishable and seven days non-perishable food supply. The food is stored probably. The facility refrigerator is maintained within the required temperature and is clean.

9. Health Related Services: The medication is centrally stored and locked by kitchen in a cabinet. LPA inspected all four (4) clients medication, and they were all updated and accurate at the time of visit. They all have 30 days’ supply of medication. PRN medications need labels and PRN authorization letters.


SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2024
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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: EXCEL ADULT HOMES
FACILITY NUMBER: 197803338
VISIT DATE: 09/03/2024
NARRATIVE
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10.Incidental Medical Services: Currently there's no client has any restricted health condition or prohibited health condition in the facility.

11. Disaster Preparedness: The facility has an emergency disaster plan and dated on 01/13/2024 and the last fire/emergency drill was conducted on 07/25/2024 and the facility has two alternative temporary shelter location. LIC 610 needs updating.

12. Emergency Intervention: The facility does not use any restraint on clients, but all staff have an updated CPI training.

Deficiencies were observed during the visit. Technical advisories provided.

Exit Interview conducted and a copy of the report and appeal rights was provided to Administrator

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2024
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 09/03/2024 04:47 PM - It Cannot Be Edited


Created By: Alberto Lopez On 09/03/2024 at 04:16 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: EXCEL ADULT HOMES
FACILITY NUMBER: 197803338

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/04/2024
Plan of Correction
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Administrator will adjust water to within meet regulations and keep a log for 7 days and send to LPA as proof.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 09/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2024


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 09/03/2024 04:47 PM - It Cannot Be Edited


Created By: Alberto Lopez On 09/03/2024 at 04:16 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: EXCEL ADULT HOMES
FACILITY NUMBER: 197803338

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)(6)(D)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (6) If the client is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (D) For every prescription and nonprescription PRN medication for which the licensee provides assistance, there shall be a signed, dated written order from a physician on a prescription blank, maintained in the client's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. 2 clients PRN medications (3) did not have Dr. orders or labels on bottles which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/17/2024
Plan of Correction
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Administrator will get doctors order with PRN authorization letters and labels for PRN and send proof to LPA by POC 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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2024


LIC809 (FAS) - (06/04)
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