197803416-12-18-2023-11-AS-SLEO-CYMV8E-20231218151236

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197803416
Report Date: 12/18/2023
Date Signed: 12/18/2023 03:12:51 PM

Document Has Been Signed on 12/18/2023 03:12 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	PADUA HOUSE		FACILITY NUMBER:	197803416
ADMINISTRATOR:	KERRI ANDERSON		FACILITY TYPE:	736
ADDRESS:	940 ATLANTIC AVENUE		TELEPHONE:	(562) 432-2000
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90813
CAPACITY: 11		CENSUS: 10	DATE:	12/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Grabriela Hernandez - Assistant Manager		TIME COMPLETED:	03:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 12/18/2023 at around 9:20 AM, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with the Assistant Manager Grabriela Hernandez. LPA explained the purpose of the visit and was accompanied by the Assistant Manager inside and outside the facility during this inspection. This facility is licensed to serve 11 adults ages 18 – 59 years, of which 5 may be non-ambulatory clients. A total of 10 ambulatory clients are currently residing in this facility. The Annual Licensing Fees are current. The facility is a two story house located on a main street. First floor consists of 2 client bedrooms, 1 toilet room, 1 bathroom, 1 kitchen, 1 dining room, 1 living room, 1 office room, 1 laundry area, 1 medicine closet, and several closets/pantries. Second floor consists of 3 client bedrooms, 1 bathroom, 1 outside patio area (doors are locked & inaccessible to clients). Facility has 1 basement. Outside grounds consists of 1 detached garage, and 1 backyard patio area with a table and shaded seating. Outside grounds were toured and no bodies of water were observed. The patio furniture is under a shaded area and accessible to clients. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. LPA toured the kitchen area and observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept in locked storage cabinet.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023

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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: PADUA HOUSE	FACILITY NUMBER: 197803416
	VISIT DATE: 12/18/2023

NARRATIVE

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LPA observed that medications were safe, locked, and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Documents are posted as mandated. Last Disaster & Fire Drill was conducted on 12/15/2023. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational. There are several fire extinguishers around the facility, and they were last serviced on 07/02/2023. There is a land line telephone in the dining room dedicated for client use. There are no videoconferencing devices (for example, computer, smart phone, tablet) dedicated for client use.

5 out of 5 client bedrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly. Adequate lighting and toiletries accessible to clients. LPA tested hot water temperature and it measured 131.7 Fahrenheit. This facility provides clients with hygiene products such as nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb. LPA observed 3 clients sharing one bedroom (Room 1 – has 3 twin size beds).

5 staff records were reviewed, 5 out of 5 staff records had current Criminal Record Clearances, Job Applications, Tuberculosis Test, Facility Trainings/Drills, and signed Employee Rights. 2 out of 5 staff records did not have current First Aid Certificates.

5 client records were reviewed and, 5 out of 5 client records had Admission Agreements, Medical Assessments, Consent Forms, Weight Record, Emergency Information, Appraisal & Needs Service Plan, Tuberculosis Test, Centrally Stored Medication Destruction Record, and Personal Rights.

Deficiencies are being cited based on LPA observation, interviews conducted and record review in accordance with the California Code of Regulations, Title 22, see LIC809D. A violation regarding no more than 2 clients shall sleep in a room, hot water temperature, First Aid Certificate, and videoconferencing device.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4

Document Has Been Signed on 12/18/2023 03:12 PM - It Cannot Be Edited

Created By: Socorro Leandro On 12/18/2023 at 02:41 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: PADUA HOUSE	FACILITY NUMBER: 197803416
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87887(d)(1)

Buildings and Grounds

(d) Bedrooms shall meet, at a minimum, the following requirements; (1) Not more than two residents shall sleep in a bedroom. 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 in 1 out of 5 bedrooms, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/19/2023
	Plan of Correction
1 2 3 4	Licensee will decrease Room 1's capacity to two clients. Licensee will email proof of correction to Socorro.Leandro@dss.ca.gov.

Type B

Section Cited

CCR

87888(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by residents 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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in hot water temperature messuring 131.7 degrees F, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/02/2024
	Plan of Correction
1 2 3 4	Licensee will fix hot water temperatures to messure 105 to 120 degrees F. Licensee will email proof of correction to Socorro.Leandro@dss.ca.gov.

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:

Ulysses Coronel

LICENSING EVALUATOR NAME:

Socorro Leandro

LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 12/18/2023 03:12 PM - It Cannot Be Edited

Created By: Socorro Leandro On 12/18/2023 at 02:41 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: PADUA HOUSE	FACILITY NUMBER: 197803416
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87923(a)(1)

First Aid Requirements

(a) All direct care staff and the facility manager shall have first aid training from persons qualified by agencies including, but not limited to, the American Red Cross. (1) A copy of the current First Aid card shall be maintained in the personnel record. 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 2 out of 5 staff, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/02/2024
	Plan of Correction
1 2 3 4	Licensee will provide time for Staff 1 and Staff 3 to complete first aid training. Licensee will email proof of correction to Socorro.Leandro@dss.ca.gov.

Type B

Section Cited

HSC

1568.074(a)

Regulations

(a) A licensee of a facility that has internet service shall provide at least one internet access device, such as a computer, smart phone, tablet, or other device, that can support real-time interactive applications, is equipped with videoconferencing technology, including microphone and camera functions, and is dedicated for client use. 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 in not having a videoconferencing device for client use, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/02/2024
	Plan of Correction
1 2 3 4	Licensee will provide a videoconferencing dedicated for client use. Licensee will email proof of correction to Socorro.Leandro@dss.ca.gov.

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:

Ulysses Coronel

LICENSING EVALUATOR NAME:

Socorro Leandro

LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023

LIC809 (FAS) - (06/04)

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