198600229-5-19-2023-28-AS-ACAN-CRYSLV-20230519135857

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600229
Report Date: 05/19/2023
Date Signed: 05/19/2023 02:00:57 PM

Document Has Been Signed on 05/19/2023 02:00 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:	CLAYTON COTTAGE GALEN		FACILITY NUMBER:	198600229
ADMINISTRATOR:	CARYN M. CLAYTON		FACILITY TYPE:	735
ADDRESS:	1248 GALEN STREET		TELEPHONE:	(626) 357-7586
CITY:	DUARTE	STATE: CA	ZIP CODE:	91010
CAPACITY: 6		CENSUS: 5	DATE:	05/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administartor - Caryn Clayton		TIME COMPLETED:	02:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced site visit for the Required - 1 Year inspection. Upon arriving at the facility LPA met with DSP worker Cecilia Becerra, shortly after met with Administrator Caryn Clayton. 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, (1) client during time of visit and (2) staff present. During today's visit, LPA used the Compliance and Regulatory Enforcement (CARE) tool, to complete the annual inspection. The physical plant was toured with Cecilia. The facility is located in a residential area. A tour of the single-story facility includes: Three bedrooms, two (2) bathrooms, living room, family/activity room, kitchen, dining area, detached garage and indoor/outdoor activity areas. All medications for clients who need assistance are kept locked and inaccessible to other clients. LPA reviewed (5) clients medication and medication log book, no deficiencies were observed. Knives, disinfectants and cleaning solutions are kept locked and inaccessible to clients in hallway storage room. The bathrooms are clean and operational, with grab bars and non-skid mats in place. Client bedrooms were checked and adequate furniture to accommodate each resident conformability was observed. The hot water temperature was tested throughout the facility and measured within Title 22 Regulation guidelines, measuring at 110 F. 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. Extra food was observed in the garage. There is a functioning telephone on the premises. Smoke detectors is combined with carbon monoxide detectors, which were tested and are operable and in compliance. LPA observed a pull-switch fire alarm in the living room. The fire extinguisher was observed in the kitchen and was fully charged. Last Fire Drill was conducted 2-13-23. The first-aid kit is fully stocked with the First-aid Manual and Emergency Supplies and PPE were observed. The washer and dryer are located in the kitchen area. Facility temperature was comfortable, measuring at 73 Degree F. (Continuation on 809-C...)

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

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

FACILITY NAME: CLAYTON COTTAGE GALEN	FACILITY NUMBER: 198600229
	VISIT DATE: 05/19/2023

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LPA Calderon reviewed a total of (6) staff files, all staff were cleared and had appropriate documentation's. LPA reviewed (5) client files and files contained appropriate documentation. No deficiencies were observed during client/staff review. Required documentation postages were observed. Administrator's certification for Caryn Clayton expires 7/15/2025 and Assistant Administrator's certification for Cameron Clayton expires 10/12/2024.

The outside was observed to have shaded area with chairs/ table provided. The backyard is free of debris/hazards and free of obstructions. No evidence of bodies of water (pool) or security bars nor weapons on the premises were observed. There is a detached garage, garage door is kept locked and inaccessible to clients at all times.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit.

Exit interview held and a copy of the report was provided.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

LIC809 (FAS) - (06/04)

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