198600141-11-30-2023-28-AS-BPEA-CY3UE5-20231130143033

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600141
Report Date: 11/30/2023
Date Signed: 11/30/2023 02:31:04 PM

Document Has Been Signed on 11/30/2023 02:31 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:	HOLY HILL INC./CARFAX HOME		FACILITY NUMBER:	198600141
ADMINISTRATOR:	FRANCISCO, ROBERT		FACILITY TYPE:	740
ADDRESS:	13831 CARFAX AVE		TELEPHONE:	(562) 867-3279
CITY:	BELLFLOWER	STATE: CA	ZIP CODE:	90706
CAPACITY:	6	CENSUS: 4	DATE:	11/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Edgardo Francisco - Administrator		TIME COMPLETED:	02:45 PM

NARRATIVE

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Licensing Program Analyst (LPA) Bennette Pena conducted the required-1 year inspection. LPA was allowed entry by Loida Carlos, Caregiver and explained the purpose of today's visit. Administrator, Edgardo Francisco arrived at 11:00am and assisted with the inspection. 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 facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan and was reviewed. Common area surfaces are being cleaned and disinfected on a regular basis. Bathrooms have soap and paper towels. Staff are adhering to infection control requirements.

Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. A fire clearance is in place. Liability Insurance policy 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 6/25/2024. Surety bond (Western Surety) of $2,000.00 is current and will expire on 03/04/2026. The last fire and emergency drill was conducted on 10/05/2023. Care and supervision to meet the residents needs was observed. Special equipment and supplies to meet the persons with special needs were observed.

Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood that is licensed to serve 6 non-ambulatory residents ages 60 and over. Current census is four (4), of which three (3) are non ambulatory and one (1) ambulatory. Facility is being serviced by Harbor Regional Center. Home consists of four (4) resident bedrooms, 2 bathrooms, living room, dining room, family room, kitchen, backyard, and a detached garage. 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. Smoke and carbon monoxide detectors are operational. The facility has (2) fire extinguishers in the facility. One (1) fire extinguisher located in the kitchen was purchased on 6/08/2023. The other (1) fire extinguisher located in the bedroom hallway was purchased today, 11/30/2023. Both bathrooms toured were observed to be fully stocked with hand soap, and paper towels, and had the required grab bars and nonskid mats in place. All showers in bathrooms accommodate non-ambulatory clients. However, LPA observed an all purpose cleaner bottle stored in an unlocked cabinet under the sink in bathroom #1. In bathroom #2, LPA observed mold and mildew in the shower area. At 10:50am, hot water temperature readings measured 112.2 deg F in the kitchen, 111.9 deg F in bathroom #1 and 109.7 deg F in bathroom #2 which are within the required 105-120 degrees Fahrenheit. Medication was observed to be centrally stored in the kitchen cabinet. ***CONTINUED ON LIC 809-C**

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

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: HOLY HILL INC./CARFAX HOME	FACILITY NUMBER: 198600141
	VISIT DATE: 11/30/2023

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Staffing: A total of thirteen (13) caregivers including the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have the required training and associated to the facility.

Personnel Records-Training: Administrator certificate is valid and will expire on 03/07/2025. Three (3) staff files were reviewed for criminal background clearance and training. Personnel records have health/TB screenings and First Aid/CPR training.

Resident Records-Incident Reports: Four (4) resident files were reviewed containing admission agreements, Physician's Report, Medical/Functional assessments, Needs and Services Plans, TB clearance, Personal rights, Medical Consent, Medication Records, Restricted Health Care Plans and Hospice Notes/Records were reviewed.

Resident Rights-Information: Resident personal rights are posted. Physician order for use of 1/2 half bed rail was reviewed in (1) resident's files.

Planned Activities: There is sufficient space to accommodate both indoor and outdoor activities. Four (4) residents attend the Day Program 2x-5x a week. Information regarding Dementia is part of the training for direct care staff and is included in the Plan of Operation.

Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7 day non-perishable food. All sharps were observed to be stored in a kitchen cabinet, which has a locked door. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. The food is properly stored in the refrigerator (clean, labeled and well maintained). Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.

Incident Medical and Dental: All residents have Restricted Health Care Plan and Needs and Services Plan on file. Not currently, but Home Health personnel serviced one (1) of the residents in the facility. Residents medication are centrally stored in a locked cabinet in the kitchen.

Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan containing emergency evacuation, storage and preservation of medications, operation of manual assist devices. The facility conducts emergency drill on a monthly basis for all staff and residents.

Residents with Special Health Needs: None of the residents are receiving home health services. Postural support physician orders are on file. Half bed rail for mobility assistance was observed in one resident in bedroom #1. Individual Service Plans and Appraisals for residents are on file. No residents have prohibited health conditions.

Deficiencies were cited, Technical Assistance was issued, exit interview conducted, and copy of the report and appeals rights were provided to the Administrator, Edgardo Francisco.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/30/2023 02:31 PM - It Cannot Be Edited

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: HOLY HILL INC./CARFAX HOME	FACILITY NUMBER: 198600141
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the Administrator did not comply with the section cited above in that LPA observed an all purpose cleaner bottle stored in an unlocked cabinet under the sink in bathroom #1, which poses an immediate health, safety or personal rights risk to residents in care.
	POC Due Date: 11/30/2023
	Plan of Correction
1 2 3 4	Administrator put it away in a locked cabinet during the visit. Deficiency cleared during the visit.

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: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 11/30/2023 02:31 PM - It Cannot Be Edited

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: HOLY HILL INC./CARFAX HOME	FACILITY NUMBER: 198600141
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)(1)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the Administrator did not comply with the section cited above in that LPA observed mold and mildew in the shower area in bathroom #2, which poses/posed a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 12/14/2023
	Plan of Correction
1 2 3 4	Administrator will ensure that the bathrooms are kept clean, safe, sanitary and in good repair at all times. Administrator will submit photos of cleaned, mold/mildew free in the shower are in bathroom #2 to CCL/LPA by POC due date.

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: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

LIC809 (FAS) - (06/04)

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