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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600088
Report Date: 08/05/2023
Date Signed: 08/05/2023 01:43:48 PM

Document Has Been Signed on 08/05/2023 01:43 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:CRESTBROOK HOMEFACILITY NUMBER:
198600088
ADMINISTRATOR:EILEEN VAZQUEZFACILITY TYPE:
735
ADDRESS:9883 CRESTBROOK STREETTELEPHONE:
(562) 866-6472
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 4CENSUS: 4DATE:
08/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:34 AM
MET WITH:Edgardo Fermin- AdministratorTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit. LPA met with Octaviano Vasquez/Direct Support Professional I & II (DSP I & II) and explained the purpose of the visit. At 11:00am Edgardo Fermin/Administrator arrived at the facility and assisted LPA with the inspection. The facility is licensed to care for Developmentally Disabled Adults, ages 18 through 59, (4) ambulatory only, with restricted health conditions. All clients residing at this facility receive case management services provided by Harbor Regional Center. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The Administrator stated that he has not submitted an Infection Control Plan. Facility does have COVID-19 signage still posted in the facility. Bathrooms have soap and paper towels. Staff are performing hand hygiene and adhering to infection control requirements.
Physical Plant and Environmental: The facility is a single storey home located in a residential neighborhood, contains a total of (4) client bedrooms and (3) full bathrooms, a living room/activity area, kitchen, dining area, den, office area by the kitchen, backyard, and detached garage. Currently, there are four (4) clients living in the facility. Facility is Level 4I. The interior and exterior physical plant was inspected. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, and sufficient closet space. LPA observed that window coverings such as blinds or curtains are missing on (3) out of (4) clients bedroom windows and some did not have window screens. LPA observed that bedroom #4 has an extra space divided by curtains containing a bed and bedroom furniture. Administrator stated it was being used as a staff room before. Bathrooms have non-skid materials and contained hygiene supplies including liquid soap, paper towels, and toilet paper. Exit doors are free of any obstruction and there are no pools or large bodies of water. Detached garage is inaccessible as it is cluttered and filled with different items such as used mattresses, large furniture and other discarded things. Kitchen knives, sharps objects, cleaning supplies and toxic substances are locked in a cabinet located in the kitchen and inaccessible to clients. There is one (1) fire extinguisher observed to be fully charged and was last serviced on 12/07/2022. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. There are no cameras in the facility. Water temperature readings measured at 109.5 deg F in bathroom #1, 114.9 deg F in bathroom #2 and 110.2 deg F in bathroom #3 which were within the required 105 - 120 degrees Fahrenheit.
Operational Requirements: A current Plan of Operation was reviewed. There is a Surety Bond Insurance in effect and valid through 4/18/2024. Administrator stated he will send a proof to CCL/LPA. Liability Insurance policy through Summa Insurance in the amount of $1,000,000.00 each occurrence and #3,000,000.00 in the total annual aggregate is valid and will expire on 3/19/2024. Fire clearance was approved for four (4) ambulatory clients only, with restricted health conditions. Fire and Disaster drills have not been conducted. Administrator showed a record of fire drill conducted on 8/2019. Outdoor/backyard activity area provides a shaded area and furnished for outdoor use.

*****REPORT CONTINUED ON LIC809-C***
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2023
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CRESTBROOK HOME
FACILITY NUMBER: 198600088
VISIT DATE: 08/05/2023
NARRATIVE
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Staffing: A total of seven (7) staff members including the Administrator provide care and supervision to the clients. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility.
Personnel Records/Staff Training: Reviewed files for two (2) staff. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Administrator certificate is valid and expiring on 10/17/2024. Administrator has a valid HIV/AIDS training proof at the time of visit. LPA conducted interviews for two (2) staff.
Client Rights-Information: Client personal rights are posted. Facility provides internet services to all clients and have access to the facility phone. One (1) client has an Ipad and a cell phone, (1) has a cell phone and (1) has 92) Ipads. LPA conducted only one (1) client interview as the other (3) clients are non verbal.
Client Records-Incident Reports: LPA reviewed Client files for C1 through C3. Client files are maintained at the facility. Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Individual Program Plan (IPP), Behavioral Reports, Functional Assessment, Needs & Services Plan, Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights observed.
Food Service: There are sufficient food supplies of 7-day non-perishable items. The food is properly stored in the refrigerator. There is (1) client with gluten-free diet residing at this facility. Pesticides and cleaning supplies are kept away from the food preparation areas and kept in locked storage room outside. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.
Health Related Services: The medications are centrally stored and in their original containers. Medications were reviewed for C1-C2 to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubbled packed.
Incidental Medical Services: According to the Administrator, there are no clients at this home with incidental medical services nor have a restricted health condition.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan.
Emergency Intervention: Not-Applicable.

Pursuant to Title 22, deficiencies were cited on the attached 809D. An exit interview was conducted, and a copy of this report was provided to Edgardo Fermin, Administrator.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 08/05/2023 01:43 PM - It Cannot Be Edited


Created By: Bennette Pena On 08/05/2023 at 01:09 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: 08/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the Administrator did not comply with the section cited above in which the Infection Control Plan has not been submitted to CCLD as required which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 08/18/2023
Plan of Correction
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Administrator agreed to develop and submit a copy of the Infection Control Plan to CCL/LPA by POC due date.

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 Administrator did not comply with the section cited above in which the detached garage is inaccessible as it is cluttered and full of miscellaneous items such as used mattresses, large furniture and other discarded things which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/18/2023
Plan of Correction
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Administrator to clear out the detached garage and remove all miscellaneous items/clutter to ensure the safety of the clients and submit written/photographic proof to CCL/LPA by POC 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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 08/05/2023 01:43 PM - It Cannot Be Edited


Created By: Bennette Pena On 08/05/2023 at 01:09 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: 08/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, 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:
Deficient Practice Statement
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Based on observation, the Administrator did not comply with the section cited above in which the window coverings such as blinds or curtains are missing on (3) out of (4) clients bedroom windows (Bedrooms #1-#3) and Bedroom #4 did not have window screens which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/18/2023
Plan of Correction
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Administrator agreed to submit picture proof evidence that the clients bedroom windows have complete window coverings and the window screen in bedroom #4 has been installed by POC due date.
Type B
Section Cited
CCR
85088(c)(1)(B)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (1) An individual bed, except that couples shall be allowed to share one double or larger sized bed, maintained in good repair, and equipped with good bed springs, a clean mattress and pillow(s). (B) No adult residential facility shall have more beds for client use than required for the maximum capacity approved by the licensing agency.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the Administrator did not comply with the section cited above in that bedroom #4 has an extra space divided by curtains containing a bed and bedroom furniture which was used as a staff room which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 08/18/2023
Plan of Correction
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Administrator agreed to clean the area and remove the bed and furniture in bedroom #4. Photo evidence shall be submitted to CCL/LPA by POC 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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 08/05/2023 01:43 PM - It Cannot Be Edited


Created By: Bennette Pena On 08/05/2023 at 01:09 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: 08/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80020(c)
Fire Clearance
(c) A licensee of an Adult Residential Facility or Group Home utilizing secured perimeters shall conduct fire and earthquake drills pursuant to Health and Safety Code section 1531.15(h).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the Administrator did not comply with the section cited above in which the Administrator has not conducted fire and disaster drills since 2019 which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 08/18/2023
Plan of Correction
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Administrator agreed to conduct the fire and disaster drills on a monthly basis and send the proof of training signed and dated by staff members to CCL/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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2023


LIC809 (FAS) - (06/04)
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