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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600265
Report Date: 08/27/2024
Date Signed: 08/27/2024 02:18:20 PM

Document Has Been Signed on 08/27/2024 02:18 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 PLACEFACILITY NUMBER:
198600265
ADMINISTRATOR/
DIRECTOR:		GARCIA, NOEYFACILITY TYPE:
735
ADDRESS:630 N. NICHOLSONTELEPHONE:
(626) 280-7205
CITY:MONTEREY PARKSTATE: CAZIP CODE:
91755
CAPACITY: 6CENSUS: 6DATE:
08/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:54 AM
MET WITH:Consuelo Diaz, DSP, Karen Gazon Marquez and Noey Garcia, Administrator. TIME VISIT/
INSPECTION COMPLETED:
02:27 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Required - 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with staff Consuelo Diaz, and explained the reason of the visit.Administrator Karen Gazon Marquez arrived a short time later. The facility is approved for serve Developmentally Disabled Adults, six (6) ambulatory clients ages 18-59.Three (3) are over 60 years of age. The facility is licensed as a level 4D home vendored by East Los Angeles Regional Center.

The following twelve (12) tool domains were observed and reviewed:

1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility still encourages hand washing, still checking client temperature twice a day and staff disinfected the facility every shift. The facility has an Infection Control Plan and COVID-19 mitigation plan in place.

2. Physical Environmental and Safety: The facility is a single story house and located on residential neighborhood area. The facility includes living room, kitchen, dining area, den/staff offices/client's activity room, Sicx (6) client bedrooms and 4 client bathrooms, laundry room and a detached garage. required furniture and bedding and sufficient lighting and closet space. The client bathrooms are clean, sanitary and in a good working condition. The hot water was tested between 106.3 – 122.8 degrees F which are not within the Title 22 regulation. The appliances in the living room and kitchen are working well. The knives and sharp utensils are stored and locked in the cabinet in kitchen. One water heat is leaking and needs repair. All the chemicals and cleaning supplies are stored and were not locked in the laundry room and not accessible to clients. The extra linen and personal hygiene products are stored in the hallway cabinet/closet. The facility does have a working landline telephone system for clients to use. The facility has night lights. LPA inspected the carbon monoxide detectors, and all smoke detectors are working. The passageway, walkway and patio are free of obstruction.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2024
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 08/27/2024 02:18 PM - It Cannot Be Edited


Created By: Alberto Lopez On 08/27/2024 at 01:34 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: ERNIE'S PLACE
FACILITY NUMBER: 198600265

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2024

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
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Based on observation, the licensee did not comply with the section cited above. Hot water measured 106.3 - 122.1 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2024
Plan of Correction
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Administrator will adjust water and keep a log for 7 days and send LPA proof.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2024


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 08/27/2024 02:18 PM - It Cannot Be Edited


Created By: Alberto Lopez On 08/27/2024 at 01:34 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: ERNIE'S PLACE
FACILITY NUMBER: 198600265

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above one water heater that is outside is leaking which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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Administrator will repair the leak and send proof to LPA by POC date.
Type B
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. food supplies are low and not enough for 7 days non perishable which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2024
Plan of Correction
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Administrator will purchase food supplies and send proof to LPA by POC date.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2024


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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ERNIE'S PLACE
FACILITY NUMBER: 198600265
VISIT DATE: 08/27/2024
NARRATIVE
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3. Operational Requirement: The facility is licensed for 6 ambulatory clients and currently all six (6) clients are ambulatory. The last fire/earthquake drill was conducted on 7/25/2024. Clients can attend the community events/activities if there's an opportunity and chance. The facility has a shaded area with table and chairs for clients to utilize the outdoor activity.

4.Staffing: The facility has sufficient staffing. LPA reviewed the NOC shift staff files, and he does have current CPR/FIRST AID certificate. Staff need facility planned emergency procedure training on how to shut off utilities.

5. Personnel Records-Training. The facility staff files are stored at facility. All the staff are over 18 years old and older, fingerprint cleared and associated with the facility. The administrator is Noey Garcia and his administrator certificate expiration date is 01/28/2026 and he has updated HIV and TB training. LPA reviewed seven (7) staff files and they all have health screening TB test result.

6. Client right-Information: Currently there's no client required postural support. The facility has internet service and provide at least one internet access device in the facility.

7. Client Records- Incident Reports: The client files are stored in the staff office in the file cabinet. All client files have the required documents include face sheet, admission agreement, functional capability assessment, health screening and TB Test, Individual Program Plan (IPP), ambulatory status and medication list.

8. Food Service: Currently no client is on modified diet. The facility does not have seven (7) days non- perishable food supply. The food is stored probably. The facility refrigerator is maintained within the required temperature.

9. Health Related Services: The medication is centrally stored and locked in a cabinet. LPA inspected all five (5) clients medication files, and they were all updated and accurate at the time of visit. They all have 30 days’ supply of medication.


SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
LIC809 (FAS) - (06/04)
Page: 5 of 6
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: 08/27/2024
NARRATIVE
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10.Incidental Medical Services: Currently there's no client has any restricted health condition or prohibited health condition in the facility.

11. Disaster Preparedness: The facility has an emergency disaster plan and dated on and the last fire/emergency drill was conducted on 07/25/2024 and the facility has two alternative temporary shelter locations. LIC 610 needs updating.

12. Emergency Intervention: The facility does not use any restraint on clients..


Deficiencies were observed during the visit. Technical Advisory provided.

Exit Interview conducted and a copy of the report was provided to Karen Gazon Marquez.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
LIC809 (FAS) - (06/04)
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