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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803752
Report Date: 09/12/2024
Date Signed: 09/12/2024 09:16:44 AM

Document Has Been Signed on 09/12/2024 09:16 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CASA DE EAST L.A. BOARD & CAREFACILITY NUMBER:
197803752
ADMINISTRATOR/
DIRECTOR:		DIANA HERNANDEZFACILITY TYPE:
735
ADDRESS:2734 EAST 5TH STREETTELEPHONE:
(323) 354-4699
CITY:LOS ANGELESSTATE: CAZIP CODE:
90033
CAPACITY: 4CENSUS: 3DATE:
09/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:43 AM
MET WITH:Carmen Juarez DSPTIME VISIT/
INSPECTION COMPLETED:
09:30 AM
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Licensing Program Analyst (LPA) Tyler Reyes met with staff Carmen Juarez Direct Support Professional (DSP) and the purpose of the visit was discussed.

***The licensing report created on 09/03/2024 is being superseded by this licensing report dated 09/12/2024. Reason the licensing report is being superseded due to missing required information relating to the LIC 809-D citation Type B Section Cited CCR 80088(b).

Physical Plant/Environment Safety:
On 08.29.24, during inspection of the physical plant LPAs observed with DSP Carmen bleach(Comet) and all purpose cleaner (Lysol) underneath the sink cabinet unlocked. LPAs observed window screens in disrepair. Locations of window screens in disrepair are in Client #1 (C1) C1,C2, restroom, and living room window closes to front door. Water temperature was tested with DSP Carmen and tested at 144.5 degrees F. Water supply needs to measure between 105-120 degrees F. On 09/03/24 during a reinspection of the physical plant LPA Reyes observed C1's PRN medication Diphenhyramine 50 MG and (2) knives a cleaver and all-purpose knife inside the staff's unlocked room. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Fire alarm system is operational.
Infection Control:
Infection control practices and Personal Protective Equipment (PPEs) were observed.

Operational Requirements:
The Program Design was reviewed.

--Continued LIC 809-C--
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Tyler Reyes
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2024
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CASA DE EAST L.A. BOARD & CARE
FACILITY NUMBER: 197803752
VISIT DATE: 09/12/2024
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Fire clearance was approved by LA County Fire Department for four (4) ambulatory developmentally
disabled clients.
Care and supervision to meet the clients’ needs was observed.

Staffing:
Observed staff members providing care and supervision to the clients.
Personnel Records/Staff Training:
Administrator’s certificate is active and effective through 01/12/26.

Four (4) staff files were reviewed for criminal background clearance and training.
Personnel records have health/TB screenings, CPI training, certifications, and 1st Aid/CPR training.

Client Rights/Information:
Physician orders were reviewed in client files.
Client Records/Incident Reports:
Two (2) client files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, nutritional assessments, medication records.

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 LIC 809-C –
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Tyler Reyes
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CASA DE EAST L.A. BOARD & CARE
FACILITY NUMBER: 197803752
VISIT DATE: 09/12/2024
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Health Related Services:
Clients are assisted with self-administration of prescription.
Two (2) centrally stored resident medication records were reviewed. Centrally stored medications are kept in a safe and locked place not accessible to clients in care. Medications are given according to Physician directions.
Incident Medical and Dental:
All clients have a Needs and Services Plan, and COVID-19 vaccination cards on file.
Staff training was on file.
Disaster Preparedness, and Emergency Intervention:
A posted Emergency Disaster Plan LIC 610D containing emergency evacuation information was observed.
An emergency drill was last documented on 07/20/24 for earthquake.

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, the deficiencies observed during the visit are documented on the LIC809D. Exit interview held and a copy of the report along with appeal rights were provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Tyler Reyes
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/12/2024 09:16 AM - It Cannot Be Edited


Created By: Tyler Reyes On 09/12/2024 at 08:53 AM
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: CASA DE EAST L.A. BOARD & CARE
FACILITY NUMBER: 197803752

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/19/2024
Section Cited

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80088(b) Furniture, Fixtures, Equipment, and Supplies (b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
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Based on observations, the licensee did not comply with the section cited above locations of window screens in disrepair are in Client #1 (C1) C1,C2, restroom, and living room window closes to front door which poses a potential health, safety or personal rights risk to persons in care.
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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:Fernando Fierros
LICENSING EVALUATOR NAME:Tyler Reyes
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024


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