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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803548
Report Date: 07/19/2024
Date Signed: 07/19/2024 04:12:57 PM

Document Has Been Signed on 07/19/2024 04:12 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CHEN'S HOME, INC.FACILITY NUMBER:
197803548
ADMINISTRATOR/
DIRECTOR:		CHEN, MARGARETFACILITY TYPE:
735
ADDRESS:5801 ALESSANDRO AVENUETELEPHONE:
(626) 456-0764
CITY:TEMPLE CITYSTATE: CAZIP CODE:
91780
CAPACITY: 4CENSUS: 4DATE:
07/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:39 AM
MET WITH:Margaret Chen, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:22 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Annual Required Visit. 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 Lopez requested and obtained copies of Personnel Report (LIC 500), and Resident Roster (LIC 9020).

The following was observed:

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

2. Physical Plant/Environment Safety:


Facility is in good repair inside and outside. Living room and dining room have sufficient lighting and sitting space. Kitchen was observed clean. Medication cabinet is locked. Cleaning supplies are under lock and key. There are sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables. Laundry area is in the by the kitchen area and machines are operable. Client's bedrooms were observed and have sufficient lighting, the required furniture and bedding supplies. Bathrooms were observed in working condition and water temperature was tested between 119.4-121.6 degrees F., which is not within the required 105-120 degrees F. Backyard has a shaded sitting area. Smoke/Carbon monoxide detector were observed, tested, and in working condition. Fire extinguishers (4) were all fully charged.

3. Operational Requirements: The Program D The following was observed:

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

(Continued on 9099C)

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7
Document Has Been Signed on 07/19/2024 04:12 PM - It Cannot Be Edited


Created By: Alberto Lopez On 07/19/2024 at 03:39 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: CHEN'S HOME, INC.
FACILITY NUMBER: 197803548

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2024

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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Based on observation, the licensee did not comply with the section cited above. water measured 121.6 at facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/20/2024
Plan of Correction
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Facility will adjust water temperature and keep 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: 07/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/19/2024 04:12 PM - It Cannot Be Edited


Created By: Alberto Lopez On 07/19/2024 at 03:39 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: CHEN'S HOME, INC.
FACILITY NUMBER: 197803548

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(g)(1)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

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 facility had cabinet where knifes are stored unlocked which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/19/2024
Plan of Correction
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Administrator locked the cabinet during the visit. ***No further action is required***
Type B
Section Cited
CCR
80073(a)
Telephones
(a) All facilities shall have telephone service on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview the licensee did not comply with the section cited above. There is no land line phone service at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2024
Plan of Correction
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Administrator will order phone services 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: 07/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2024


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 07/19/2024 04:12 PM - It Cannot Be Edited


Created By: Alberto Lopez On 07/19/2024 at 03:39 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: CHEN'S HOME, INC.
FACILITY NUMBER: 197803548

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. one staff did not have health screening which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2024
Plan of Correction
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Administrator will obtain health screening for staff and send to LPA by POC date.
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. 2 staff did not have first aid training (CPR) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2024
Plan of Correction
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Administrator will get all staff trained in first aid and send CPR certificates 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: 07/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2024


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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: CHEN'S HOME, INC.
FACILITY NUMBER: 197803548
VISIT DATE: 07/19/2024
NARRATIVE
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2. Physical Plant/Environment Safety:
Facility is in good repair inside and outside. Living room and dining room have sufficient lighting and sitting space. Kitchen was observed clean. Medication cabinet is locked. Cleaning supplies are under lock and key. Thermometers were observed in the freezer at 0 degrees F. Refrigerator has a thermometer. Laundry area is in by the kitchen area. Client's bedrooms were observed and have sufficient lighting, the required furniture and bedding supplies. Bathrooms were observed in working condition and water temperature was tested between 119.4 - 121.6 degrees F., which is not within the required 105-120 degrees F. Backyard has a shaded sitting area. Smoke/Carbon monoxide detector were observed, tested, and in working condition. Fire extinguisher are all fully charged

3. Operational Requirements: The Program Design was reviewed. Fire clearance was approved by LA County Fire Department for twenty- approved for 4 ambulatory clients. Care and supervision to meet the clients’ needs was observed.


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

5. Personnel Records/Staff Training: Administrator’s certificate expires 11/07/2024 Staff files were reviewed for criminal background clearance and training. Personnel records do not have health/TB screenings or 1st Aid/CPR training for 2 staff

6. Client Rights/Information: Personal rights are posted near the entrance.

7. Client Records/Incident Reports: Four (4) client files were reviewed containing admission agreements, 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.

(Continued)

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

DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024
LIC809 (FAS) - (06/04)
Page: 6 of 7
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: 07/19/2024
NARRATIVE
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9. Health Related Services: Clients are assisted with self-administration of prescription and non-prescription medications. four (4) 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: All clients have a Needs and Services Plan, and COVID-19 vaccination cards on file.

11. Disaster Preparedness, and Emergency Intervention: A posted Emergency Disaster Plan LIC 610D containing emergency evacuation information was observed but facility needs to train staff on location and instructions of shutting off utilities.


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 are documented on the LIC809D. 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: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024
LIC809 (FAS) - (06/04)
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