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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198200906
Report Date: 03/15/2024
Date Signed: 03/15/2024 03:09:37 PM

Document Has Been Signed on 03/15/2024 03:09 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:ALTIUS II ADULT RESIDENTIALFACILITY NUMBER:
198200906
ADMINISTRATOR:PEDRO PEREZFACILITY TYPE:
735
ADDRESS:3745 W. 157TH STREETTELEPHONE:
(310) 973-8249
CITY:LAWNDALESTATE: CAZIP CODE:
90260
CAPACITY: 6CENSUS: 4DATE:
03/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:36 AM
MET WITH:Maricela PacheecoTIME COMPLETED:
03:30 PM
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On 03/15/24, Licensing Program Analyst (LPA) Wendy Gibbs conducted an unannounced required annual visit using the CARE Inspection Tools. Upon arrival at the facility, LPA met with House Manager, Maricela Pacheeco, and explained the purpose of today’s visit. Currently the facility has 4 Clients. One client was present during today’s visit.
Structure The facility is a single-story home in a residential neighborhood. The facility consists of 3 bedrooms, 1 and ½ bathrooms, living room, dining room, kitchen, office room and laundry area.
Physical Plant LPA and House Manager toured the inside and outside grounds of the facility. In the living room is a fireplace with a screen over the front. House manager stated they do not use the fireplace. In the backyard, LPA observed a shaded outdoor area with a table and chairs. The front and backyard are maintained. All walkways are clean, clear, and free of obstructions, hazards, and debris. All gates on the side of the house open easily from the backyard. LPA did not observe any bodies of water on the premises.
Bedrooms LPA inspected all client bedrooms. LPA observed they had the required furniture including bed, dresser, nightstand, lamp, chair available, and ample storage space. LPA observed all beds to have the required linens including a mattress cover, fitted sheets, blankets, comforter and pillow. All bedrooms had
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE: DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/15/2024
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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ALTIUS II ADULT RESIDENTIAL
FACILITY NUMBER: 198200906
VISIT DATE: 03/15/2024
NARRATIVE
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ample lighting. In Client’s rooms, LPA observed puzzles, games, toys, and activities.
Bathrooms LPA inspected all bathrooms. LPA observed sufficient liquid soap, and paper towels available for clients. Toilets and water faucets were operational, grab bars were secure, and a non-skid mat was in place. The water temperature measured at 115-degrees Fahrenheit in client bathroom.
Linens & Hygiene LPA observed an ample supply of towels, bed linens, blanket, comforters, and pillows in the cabinet in the hallway. LPA observed Clients personal hygiene products in a box in their room, extra supplies in the hall cupboard and additional supplies stored in the closet in the office.
Kitchen LPA inspected the kitchen and observed a three-day supply of perishable and a seven-day supply of non-perishable food. LPA observed all food properly stored, packaged, and labeled. LPA observed all dishware, cookware, and cutlery to be in good repair. All appliances were in good working repair. All knives and sharps are secured in a locked cabinet in the office and are inaccessible to clients. All toxins and cleaning supplies were secured in a locked storage cabinet located in the laundry room and are inaccessible to clients. The water temperature in the kitchen measured 115.1-degrees Fahrenheit.
Common Rooms LPA toured all common rooms. The dining room has a long rectangular table and enough chairs to accommodate all clients. In the living room is a couch, 2 recliners and a chair to accommodate all clients. All walkways inside the home were observed clean, clear, and free of hazards and obstructions. All rooms and hallways had ample lighting. A comfortable temperature was maintained in the facility.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ALTIUS II ADULT RESIDENTIAL
FACILITY NUMBER: 198200906
VISIT DATE: 03/15/2024
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Safety LPA observed a fully charged fire extinguisher mounted on the wall in the kitchen, with the receipt. All smoke detectors were tested and are fully operable. The carbon monoxide detector is operable. LPA observed a fully stocked First Aid Kit containing all required items and a manual. The last emergency drill was conducted on 02/15/24. LPA observed a working landline telephone. LPA observed all required documents posted. Due to clients taking posting off the walls they are posted in the laundry area next to the office.
Infection Control During the tour, LPA observed the facility’s infection control practices. LPA reviewed the Client’s daily temperature log and Covid symptom log. LPA observed PPE supplies are readily available to staff, and an additional 60-day supply of PPE was stored in the office. Sufficient paper, cleaning, and disinfecting supplies were observed. LPA observed infection control posting at the front door and in the laundry area and bathrooms.
Medications Centrally stored medications were observed stored in their originally received containers and secured in a locked cabinet in the kitchen and are inaccessible to clients. LPA reviewed three (3) client medications and client Medication Administration Record (MAR). LPA observed the MARs and medication are consistent with properly documented records.
Files LPA reviewed four (4) client files and found they contained the required documents. LPA reviewed five (5) staff files and found they did not have all the required documents. LPA reviewed the training logs for all staff. LPA reviewed the P & I for the Clients. LPA observed all licensing fees are current.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ALTIUS II ADULT RESIDENTIAL
FACILITY NUMBER: 198200906
VISIT DATE: 03/15/2024
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Interviews LPA interviewed House Manager who was able to answer questions regarding client care, procedure, policy, and personal rights.

Deficiencies are cited on the attached LIC809-D.

An exit interview was conducted, and a copy of this report was provided to Maricela Pacheco.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/15/2024 03:09 PM - It Cannot Be Edited


Created By: Wendy Gibbs On 03/15/2024 at 02:17 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: ALTIUS II ADULT RESIDENTIAL
FACILITY NUMBER: 198200906

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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, the screen on the front door is torn and the handle is broken, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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Licensee will either replace the screen and handle on the front screen door or purchase a new screen door. Licensee will send a picture to LPA of fixed screen door or new door.
Type B
Section Cited
CCR
85165(d)(1)
85165 Emergency Intervention Staff Training (d) The emergency intervention training curriculum shall address, at a minimum, the following, (1) Techniques of group and individual behavior management, including, but not limited to,crisis prevention and intervention, positive behavioral supports, and precipitating factors leading to assultive behavior.

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 in staffs Crisis Prevention Intervention (CPI) training has expired which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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Licensee will ensure staff receive Crisis Prevention Training (CPI) and email a copy of staffs cards to LPA on or before the plan of correction due 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:Eva M Alvarez
LICENSING EVALUATOR NAME:Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2024


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