198600155-1-23-2024-28-AS-NMAN-CZRUF6-20240123143214

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600155
Report Date: 01/23/2024
Date Signed: 01/23/2024 02:32:20 PM

Document Has Been Signed on 01/23/2024 02:32 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:	SOUTHERN CALIFORNIA ASSISTED LIVING		FACILITY NUMBER:	198600155
ADMINISTRATOR:	RYAN MAGNO		FACILITY TYPE:	735
ADDRESS:	1510 EDANRUTH AVENUE		TELEPHONE:	(626) 813-2552
CITY:	LA PUENTE	STATE: CA	ZIP CODE:	91746
CAPACITY: 6		CENSUS: 6	DATE:	01/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Sison Sir		TIME COMPLETED:	02:45 PM

NARRATIVE

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Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced annual visit using the Care Tool. LPA met with staff Sison Sir. LPA explained the reason for the visit. House Manager Leilani Telebrico arrived shortly after and assisted with the visit. The facility is approved for six (6) ambulatory developmentally disabled adults, ages 18-59. There are currently six (6) clients residing in this facility and receive services from San Gabriel/Pomona Regional Center.

This is a single-story home located in a residential neighborhood and consists of the following: 4 clients bedrooms, living room, dining area, stock / supply room, office, 1 clients bathroom, 1 staff bathroom (inside of office), kitchen and laundry. The facility has an open front yard and enclosed backyard with an attached patio cover. The front and backyard are well maintained and there are no pools or large bodies of water. Passageways and exits are free of obstruction. Client bedrooms and bathroom were checked. Each bedroom is equipped with the proper furnishings. Bedrooms also have sufficient closet space. The bathroom is clean and have the required hygiene items. The hot water temperature was tested and was measured at 124.5 degrees F. Extra linens, blankets, towels, and personal hygiene supplies were observed. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and working properly. Sharps are locked and are inaccessible to clients. LPA observed laundry detergent, cleaning solutions/disinfectants are stored and locked in the laundry. 2 fire extinguishers observed in the laundry and in the living room fully charged. Carbon monoxide/smoke detectors in the hallway / living room and in the client rooms are operational.

Continued 809C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

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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Document Has Been Signed on 01/23/2024 02:32 PM - It Cannot Be Edited

Created By: Nune Margaryan On 01/23/2024 at 12:39 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: SOUTHERN CALIFORNIA ASSISTED LIVING	FACILITY NUMBER: 198600155
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/23/2024

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, the licensee did not comply with the section cited above in the clients bathroom the hot water was measured at 124.5 degree F, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/23/2024
	Plan of Correction
1 2 3 4	Water temperature was adjusted at the time of visit. The licensee will ensure that the hot water temperature is maintained between 105 degrees F - 120 degrees F as required and submit a log for the next 24 hours showing the actual reading in the client bathroom.

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:

Wei Siew Ho

LICENSING EVALUATOR NAME:

Nune Margaryan

LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SOUTHERN CALIFORNIA ASSISTED LIVING	FACILITY NUMBER: 198600155
	VISIT DATE: 01/23/2024

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The First Aid kit was fully stocked with all required items including a current manual. Centrally stored medications are stored in a locked cabinet in the living room. LPA reviewed clients and staff files. LPA confirmed staff working have fingerprint clearances. LPA reviewed clients medications. Medications are documented properly and given as prescribed.

Observed deficiency is documented on 809D.

Exit interview conducted with House Manager Leilani Telebrico and the copy of the report and appeal rights are provided.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

LIC809 (FAS) - (06/04)

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