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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600088
Report Date: 09/23/2022
Date Signed: 09/23/2022 01:21:22 PM

Document Has Been Signed on 09/23/2022 01:21 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CRESTBROOK HOMEFACILITY NUMBER:
198600088
ADMINISTRATOR:EILEEN VAZQUEZFACILITY TYPE:
735
ADDRESS:9883 CRESTBROOK STREETTELEPHONE:
(562) 866-6472
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 4CENSUS: 4DATE:
09/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Edgardo Fermin- AdministratorTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst's (LPA's) V. Maldonado and K. Ramirez made an unannounced visit to the facility to complete the required annual inspection. LPA's Maldonado and Ramirez met with staff Sidney Lopez and explained the purpose of the visit. Administrator Edgardo Fermin arrived shortly after to assist with the visit. LPA's used the infection control tool to evaluate the facility. During today's visit, LPA's toured the physical plant with the administrator. Food and PPE supplies were observed, COVID-19 procedures were reviewed, staff files were checked for criminal background clearance and training, and client medications and files were reviewed for updated emergency information. The facility is licensed to serve developmentally disabled adults ages 18- 59 years old, ambulatory only, with restricted health conditions.

The facility is a home located in a residential area. It consists of 4 client bedrooms, 3 bathrooms, a kitchen, a living room, a dining room, a TV room, a laundry room, and a detached garage. All walkways, passageways, and entrances/exits were free of obstruction, debris, and hazards. LPA's observed all resident bedrooms to have the required bedding, linens, furniture, and sufficient lighting. Bathrooms#1-#3 (RR1-RR3) were observed to have a working toilet, shower, and wash basin. The water temperature was tested and measured at 109*F in RR1, 113.9*F in RR2, and 115.3*F in RR3.

At 9:24 a.m., RR2 was observed to have dirty cabinet doors/shelves, a dirty bathtub that had mold, a tile in the bathtub was cracked/broken, the shower curtain rod was broken and taped together with black tape, and one of the cabinet doors was broken/missing. At 10:49 a.m., LPA's observed RR3 door to have chipped paint on the inside and outside. A broken tile on the wall was also observed right outside of RR3, near a light switch.

The backyard has a shaded patio and additional seating. At 9:34 a.m., LPA's observed the patio seating to have dust and derbis from trees and 2 water bottles of cigarette butts were observed on a counter next to the patio seating area. (Report Continued on LIC809-C...)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2022
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CRESTBROOK HOME
FACILITY NUMBER: 198600088
VISIT DATE: 09/23/2022
NARRATIVE
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LPA's also observed the ceiling fan above the dining table to have an excessive amount of dust collected.

At 9:40 a.m., a cabinet drawer in the kitchen, next to the pantry, was broken with the cover left inside.

LPA's observed 1 refrigerator and freezer operating and in good repair. The food supply in the facility was observed and it was discovered there was insufficient and no variety of nutritious foods, non-perishables for 2-days, for 4 clients in care. No emergency food supplies was observed. All sharps were observed to be locked and stored in a kitchen cabinet next to the sink. There is a passageway leading to the laundry room from the kitchen, which remains open and accessible for client use. All toxins/cleaning supplies were observed to be locked and stored in a cabinet in the laundry room. There was a fire extinguisher observed in the TV room that is operational and fully charged. The smoke detectors were observed in every room and are interconnected. They were tested/operational during today's visit. There was no carbon monoxide detector observed at the facility during today's inspection. COVID-19 signage was only available at the entrance and not available throughout the facility to promote handwashing, mask wearing, social distancing, and cough/sneeze etiquette. Personal Protection Equipment (PPE) was unavailable throughout the facility for client/staff/visitor use. There was no central entry point for visitor/staff/client check of symptoms/temperature check. The facility was observed to have sufficient PPE for 30 days. The first aid kit was observed to have the required items; However it was missing the required first aid manual.

LPA's reviewed 6 staff files for criminal background clearances, required training, first aid/CPR certification, and health screenings. (6) of (6) staff files were missing required documents, 1 staff had a missing TB Clearance, and 3 staff had expired first aid certification. LPA's also reviewed 4 client files for updated emergency contact information and health screenings. All client files reviewed had the required documents. Medications for 4 clients in care were reviewed. All medications bubble packs coincided correctly on the Medication Administration Records (MAR) with the date/times administered.

Per California Code of Regulations, Title 22, deficiencies were observed during today's visit and will be cited on the LIC809-D.

An exit interview was conducted with administrator Edgardo Fermin and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 09/23/2022 01:21 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 09/23/2022 at 12:42 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: CRESTBROOK HOME
FACILITY NUMBER: 198600088

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1503.2
§1503.2 Carbon monoxide detectors required; inspection
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with having a carbon monoxide detector available in the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2022
Plan of Correction
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Licensee will obtain a carbon monoxide detector and install it in the facility. A picture of the intalled device with the receipt will be emailed to LPA by POC due date.
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:Fernando Fierros
LICENSING EVALUATOR NAME:Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/23/2022 01:21 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 09/23/2022 at 12:46 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: CRESTBROOK HOME
FACILITY NUMBER: 198600088

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
80087 Buildings 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 having a facility that is clean, sanitary, and in good repair. LPA observed RR2 to be dirty with mold, broken tile in the bathrub, missing cabinet doors, broken drawer in the kitchen, patio furniture with dust and debris, and a ceiling fan with excess dust, and a torn laminate tile outside of RR3 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/14/2022
Plan of Correction
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Licensee will clean and repair the items listed and send a picture of the corrections to LPA via email by the POC due date.
Type B
Section Cited
CCR
85076(d)(1)
85076 Food Service
(d)The licensee shall meet the following food supply and storage requirements:(1)Supplies of... fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not have sufficient fresh parishable foods for 4 clients during the time of the visit which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2022
Plan of Correction
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Licensee will send LPA a picture via email of the grocery receipt and of the foods purchased in the refrigerator by the POC due date. A variety of nutritious foods.
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:Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/23/2022 01:21 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 09/23/2022 at 01:02 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: CRESTBROOK HOME
FACILITY NUMBER: 198600088

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(11)&(12)
80066 Personnel Records
(11)Tuberculosis test documents…
(12)For employees that are required to be fingerprinted …:(A) A signed statement regarding their criminal record history...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 6 staff files reviewed were missing LIC508, first aid certification, and 1 staff missing TB clearance which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/14/2022
Plan of Correction
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Licensee will obtain the required documents and complete staff files. A copy of the required files will be emailed to LPA by the POC due date.
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:Fernando Fierros
LICENSING EVALUATOR NAME:Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2022


LIC809 (FAS) - (06/04)
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