197803548-7-22-2023-28-AS-KRAZ-CTYQVZ-20230722123110

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197803548
Report Date: 07/22/2023
Date Signed: 07/22/2023 12:31:26 PM

Document Has Been Signed on 07/22/2023 12:31 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:	CHEN'S HOME, INC.		FACILITY NUMBER:	197803548
ADMINISTRATOR:	CHEN, MARGARET		FACILITY TYPE:	735
ADDRESS:	5801 ALESSANDRO AVENUE		TELEPHONE:	(626) 456-0764
CITY:	TEMPLE CITY	STATE: CA	ZIP CODE:	91780
CAPACITY: 4		CENSUS: 4	DATE:	07/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Margaret Chen		TIME COMPLETED:	01:00 PM

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 07/22/2023 at 8:55 am. LPA was met by Licensee Margaret Chen and explained the purpose of the visit. The facility is licensed serve developmentally disabled clients 18-59 years old. All clients receive services from East Los Angeles Regional Center. LPA Ramirez requested and obtained copies of Personnel Report (LIC 500), and Resident Roster (LIC 9020).

LPA OBSERVATIONS: Tour began at 9:10 am and was led by Margaret Chen. The facility is a single-story building located in a residential area with three (3) client bedrooms, one (1) staff bedroom, two (2) bathrooms, kitchen, dining room, living room, den, front yard, backyard, and detached garage.

Front Yard: Was clean and well maintained. No hazards were observed.

Kitchen: LPA Ramirez observed appliances to be clean and in working order. LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located kitchen cabinet, to be inaccessible to four (4) out of four (4) clients in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants located in bottom kitchen cabinet to be inaccessible to four (4) out of four (4) clients in care. Kitchen sink water temperature was measured at 117.9 degrees F.

Dining Room/Living room/Den: Dining room was observed to be clean and contained one table with plenty of seating. Living room was observed with plenty of seating and lighting. LPA Ramirez observed fully charged fire extinguisher in dining room closet. Den was observed to be clean and contain plenty of seating and lighting.

Linen Closet: Contained plenty linens, towels, and hygiene products.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CHEN'S HOME, INC.	FACILITY NUMBER: 197803548
	VISIT DATE: 07/22/2023

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Client Rooms 1 - 3: LPA Ramirez observed all resident bedrooms to contain the required linens, furnishings, and lighting. LPA Ramirez observed client mattresses did not have required mattress pads or rubber sheeting on any of the client beds. Per Licensee Chen, they were recently removed due to the hot weather. LPA Ramirez did observe four (4) extra mattress protectors in linen closet. Chen placed protectors back on all four client mattresses during visit. Technical Advisory was issued. LPA Ramirez observed client bedroom #2 to contain two (2) beds and two (2) dressers. Per Licensee Chen, the facility use to have 6 clients in care. The facility recently decreased capacity in February of 2023. Licensee Chen stated this room is not being used for clients.

Bathrooms: Water temperature in resident bathroom#1 was measured at 114.8 degrees F which is in the required 105 – 120 degrees F. Shared bathroom #2 was observed to be clean and water temperature was measured at 109.7 degrees F which is in the required 105 – 120 degrees F.

Centrally Stored Medications: LPA observed cabinet located in staff office to be locked and inaccessible to residents in care.

Backyard: LPA observed plenty of seating and shade. No large bodies of water were observed.

Emergency Drills(Conducted every 6 months): Proof of last documented fire drill was conducted 6/15/23.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide and smoke detectors in hallways. Smoke detectors were tested during visit.

Staff Personnel Files: Staff files are maintained at facility. Two (2) staff files were reviewed. LPA Ramirez reviewed current First Aid/CPR certification, Health Screening and Tuberculosis Screening on file, Criminal record clearance, and initial training.

Resident Files: Four (4) resident files were reviewed. Admissions agreements, resident personal rights, and recent (2023) Individual Personal Plan (IPP) were observed in files.

Infection Control Plan: Licensee will submit updated copy of Infection Control Plan to LPA Ramirez by 8/5/23 or LPA Ramirez may return to issue deficiency.

No deficiencies are being cited. Two (2) Technical Advisory’s and one (1) Technical Violation was issued during visit. Exit interview was conducted Licensee Chen and a copy of this report, 809-D, LIC 9102TA, LIC 9102 TV, and appeals rights were provided.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2023

LIC809 (FAS) - (06/04)

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