198202435-10-28-2023-11-AS-LMOA-CX2RER-20231028125758

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198202435
Report Date: 10/28/2023
Date Signed: 10/28/2023 12:58:04 PM

Document Has Been Signed on 10/28/2023 12:58 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	MARIPOSA HOUSE (HFL HARBOR GATEWAY HOMES)		FACILITY NUMBER:	198202435
ADMINISTRATOR:	LIESS, CAROL M		FACILITY TYPE:	735
ADDRESS:	21218 MARIPOSA AVE		TELEPHONE:	(310) 781-3045
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90502
CAPACITY: 6		CENSUS: 6	DATE:	10/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:01 AM
MET WITH:	LOURDES BALONGLONG		TIME COMPLETED:	01:15 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 10/28/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA met with caregiver Lourdes Balolong and explained the purpose of today’s visit. The facility is licensed to operate for six (6) ambulatory clients between the ages of 18 through 59. The facility is a single-story structure located in a residential neighborhood. It consists of the following: three (3) client bedrooms, one (1) office, one (1) staff room, three (3) bathrooms, two (2) living areas, one (1) dining area, laundry area, kitchen, a two-car garage and outside shaded patio area. At around 9:20 AM, LPA Montoya and Balolong toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of the visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature in two client bathrooms adjacent to each other were 124.6 degree F and 124.7 degree F. A comfortable temperature of 75 degrees was maintained in the facility. LPA Montoya observed the facility to be sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food supply. There are three (3) fully charged fire extinguishers serviced on 1/27/2023. Smoke detectors and carbon monoxide were operable. A review of Medication Records Administration (MARs) was conducted and was observed to be maintained in order and accurate. Several landline phones were available and operable. The last Fire Drill was conducted on 10/27/2023. Administrator's Certificate expires on 2/25/2025. Evaluation Report continues LIC 809-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2023

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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: MARIPOSA HOUSE (HFL HARBOR GATEWAY HOMES)	FACILITY NUMBER: 198202435
	VISIT DATE: 10/28/2023

NARRATIVE

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At around 10:15 AM, LPA Montoya reviewed six out of six client files and three out of ten staff files. All reviewed client and staff files were current and updated with required records.

At around 11:20 AM, LPA Montoya and Caregiver Balolong reviewed six out of six clients' P&I and counted the cash on hand. The clients' P&I records are correct and accurate.

At around 11:30 AM, LPA conducted an interview with one out of one on-duty staff.

At around 12:00 PM, LPA conducted an interview with five out of six clients.

LPA Montoya observed the following deficiency:

1. The water temperature in two client bathrooms adjacent to each other were 124.6 degree F and 124.7 degree F.

A deficiency is being cited based on LPA observation, interview conducted and record review in accordance with the California Code of Regulations, Title 22, see LIC809D.

An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with Caregiver Lourdes Balolong.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/28/2023 12:58 PM - It Cannot Be Edited

Created By: Lourdes Montoya On 10/28/2023 at 11:51 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: MARIPOSA HOUSE (HFL HARBOR GATEWAY HOMES)	FACILITY NUMBER: 198202435
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/28/2023

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
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above. On 10/28/2023 at 9:55 AM, LPA Montoya and Caregiver Balolong checked the water temperature in two client bathrooms adjacent to each other. The water temperature was measured at 124.6 degree F. and 124.7 degree F. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/29/2023
	Plan of Correction
1 2 3 4	Caregiver Balolong agreed to adjust the water temperature and check the temperature every two hours. A 24-hour record of water temperature from 10/28/23-10/29/23 shall be recorded and shall be submitted to CCLD. POC shall be submitted via email to lourdes.montoya@dss.ca.gov by the POC due date, 10/29/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Stephanie Cifuentes

LICENSING EVALUATOR NAME:

Lourdes Montoya

LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2023

LIC809 (FAS) - (06/04)

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