198600265-9-9-2023-28-AS-THEA-CVHR7A-20230909124601

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600265
Report Date: 09/09/2023
Date Signed: 09/09/2023 12:46:11 PM

Document Has Been Signed on 09/09/2023 12:46 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:	ERNIE'S PLACE		FACILITY NUMBER:	198600265
ADMINISTRATOR:	LAN LY		FACILITY TYPE:	735
ADDRESS:	630 N. NICHOLSON		TELEPHONE:	(626) 280-7205
CITY:	MONTEREY PARK	STATE: CA	ZIP CODE:	91755
CAPACITY: 6		CENSUS: 6	DATE:	09/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:53 AM
MET WITH:	Noey Garcia - Administrator		TIME COMPLETED:	01:00 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) Tena Herrera conducted an unannounced visit for an Annual Inspection. Upon arrival, LPA met with Mayra Espinoza (DSP) and Noey Garcia (Administrator) who later assisted with the visit. The purpose of the visit was explained upon arrival. The facility is licensed to serve 3 Ambulatory and 3 Non-Ambulatory Developmentally Disabled Adult Adults, ages 18-59 years old. The two-story facility is located in a residential area in Monterey Park, Ca. The first floor has: 6 client bedrooms, 3 bathrooms, living room, dining area, kitchen, laundry area, office, back yard with shaded patio, and a detached garage. Second floor has: 3 rooms (used as storage and offices) and 1 bathroom. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: The facility staff are using appropriate hand hygiene while assisting clients’ medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan. Physical Plant & Environment Safety: There are 6 client bedrooms, 1 Heath Coordinator Office, 1 Administrator Office, 1 Storage Room, 4 bathrooms, kitchen, laundry room, living room, dining area, Staff Office, detached garage, and outside patio. All client bedrooms had the required furniture for comfort and safety and had sufficient lighting. All outdoor passages were free of obstruction. Bathrooms were clean, toilets and water faucets worked properly. Water temperature was measured throughout the facility and were within the required range of 105 – 120 Degrees F. Client bath towels, toiletries and personal hygiene supplies were adequately available. All storage areas for cleaning solutions, toxins, knives, and hazardous items are securely stored and inaccessible to clients. Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguisher was observed to be fully charged. (Continued on 809-C)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2023

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: ERNIE'S PLACE	FACILITY NUMBER: 198600265
	VISIT DATE: 09/09/2023

NARRATIVE

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Operational Requirements: The facility has the appropriate fire clearance. The last Fire/Emergency Drill was conducted on 04/27/23. There is an outdoor activity area that is shaded and furnished for outdoor use.
Staffing: There appears to be sufficient staffing at all times in the facility. Administrator Noey Garcia furnished proof of pending application for administrator certificate with CCL receipt of 6/27/23.
Personnel Records-Training: Staff has criminal record clearance. Staff have current CPR/first aid training and sufficient on-going training.
Client Rights-Information: Facility provides internet and telephone access for the clients in care.
Client Records-Incident Reports: Client files are kept in a secured location and have the following documents in their files – Regional Center Admission Agreement, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan.
Food Service: 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.
Health Related Services: Medications for residents are securely stored in a locked cabinet. All medication observed during visit were properly labeled and in their original containers.
Incidental Medical & Dental: Staff designated to administer medication has the proper annual training on file.
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Emergency Intervention: Residents at this facility do not have restraints nor do they require the use de-escalation techniques.

LPA conducted 3 staff interviews and 2 client interviews during today’s visit.

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

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

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2023

LIC809 (FAS) - (06/04)

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