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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600229
Report Date: 07/13/2022
Date Signed: 07/14/2022 07:59:10 AM

Document Has Been Signed on 07/14/2022 07:59 AM - 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:CLAYTON COTTAGE GALENFACILITY NUMBER:
198600229
ADMINISTRATOR:CARYN M. CLAYTONFACILITY TYPE:
735
ADDRESS:1248 GALEN STREETTELEPHONE:
(626) 357-7586
CITY:DUARTESTATE: CAZIP CODE:
91010
CAPACITY: 6CENSUS: 5DATE:
07/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:House Manager / Tina HardyTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced site visit for the Required - 1 Year inspection. Upon arriving at the facility LPA met with House Manager / Tina Hardy who assisted with the visit. The facility is licensed to serve six (6) Developmentally Disabled Clients ages 18 - 59 years of age. The facility is approved for six (6) Ambulatory clients only. Currently, there are five (5) clients in placement. During today's visit, LPA used the infection control domain to complete the Required - 1 Year inspection. Also, the physical plant was toured, medication and food supplies reviewed.

There is only one entrance being utilized at the facility. COVID -19 related materials were posted on the main door. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available.

The facility is located in a residential area. A tour of the single-story facility includes: Three (3) client bedrooms, two (2) bathrooms, living room, family/activity room, kitchen, dining area, and indoor/outdoor activity areas. All medications for residents who need assistance are kept locked and inaccessible to other clients. Knives, disinfectants and cleaning solutions are kept locked and inaccessible to clients. The bathrooms are clean and operational. Client bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The hot water temperature was tested throughout the facility and measured within Title 22 Regulation guidelines. The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. There is a functioning telephone on the premises. The facility has central air and heating accommodations. LPA reviewed client medications.



Smoke detectors and carbon monoxide detectors are operable and in compliance. LPA observed a pull-switch fire alarm in the living room. The fire extinguisher was observed in the family/activity room and was fully charged and in compliance. The first-aid kit is fully stocked w/First-aid Manual. The front yard is well
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2022
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: CLAYTON COTTAGE GALEN
FACILITY NUMBER: 198600229
VISIT DATE: 07/13/2022
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landscaped with steps that leads to the entry. A shaded area with chairs is provided in the back yard. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. The outdoor activity area is free of visible hazards and debris and the trash cans have covered lids. There is no evidence of bodies of water (pool) or security bars nor weapons on the premises. The washer and dryer are located in the kitchen area. There is a detached two car garage with additional storage of food supply. The garage door is kept locked and inaccessible to clients at all times.

During today's walk through, LPA observed COVID-19 prevention/protocol signs posted throughout the facility.

The following concern was observed during today's visit;

  • At 12:55pm, LPA discovered that PRN medication Promethazine Sol 6.25/5 ML (Give 10 ML by mouth every 6 hours as needed for cough/congestion) was missing from the facility and not being administered to Client #1 (C1) per physician's directions.



An advisory note was also issued during today's visit (please see LIC 9102).
The following deficiency was observed to be in violation of California code of Regulations, Title 22, Division 6 (refer to 809D)

An exit interview was conducted and a copy of this report was provided along with the Appeals Rights.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/14/2022 07:59 AM - It Cannot Be Edited


Created By: Joe Katrdzhyan On 07/13/2022 at 01:08 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: CLAYTON COTTAGE GALEN
FACILITY NUMBER: 198600229

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/14/2022
Section Cited

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Health Related Services. Once ordered by the physician the medication is given according to the physician's directions.


This requirement is not met as evidenced by;
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At 12:55pm, LPA discovered that PRN medication Promethazine Sol 6.25/5 ML (Give 10 ML by mouth every 6 hours as needed for cough/congestion) was missing from the facility and not being administered to Client #1 (C1) per physician's directions.
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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:Wei Siew Ho
LICENSING EVALUATOR NAME:Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2022


LIC809 (FAS) - (06/04)
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