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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600312
Report Date: 05/17/2022
Date Signed: 05/17/2022 12:36:52 PM

Document Has Been Signed on 05/17/2022 12:36 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:KOCH-VAGTHOL'S METABOLIC RESIDENTIAL CENTERFACILITY NUMBER:
198600312
ADMINISTRATOR:CHAMU-NESTOR, FRANCISCAFACILITY TYPE:
735
ADDRESS:753 SOUTH MARIPOSA STREETTELEPHONE:
(818) 843-2695
CITY:BURBANKSTATE: CAZIP CODE:
91506
CAPACITY: 6CENSUS: 5DATE:
05/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:11 AM
MET WITH:Administrator Fransica Chamu-NestorTIME COMPLETED:
12:46 PM
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Licensing Program Analyst (LPA) Alberto Lopez and Bennette Pena conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPAs met with House manager Emmeline Baldoza and Administrator Fransica Chamu-Nesto and explained the purpose of the visit. Home is Specialize home. The home has 5 ambulatory clients, none have a restricted health care condition and 2 clients are between the ages of 18-59. 3 clients are over 60 and facility has age exemption for 2. Facility is a one-story home located in a residential area consisting of 5 private rooms and 2 staff rooms,2 bathrooms, 1staff bathroom, living room, dining room, backyard patio area, and detached garage. The last fire drill was completed on March 21,2022. Administrator certificate expires 10/08/2023

The following were observed/inspected:

· COVID-19 signs are posted at the entrance. Visitors are screened in the main entrance and a log is kept.
· Infection control signs and other COVID-19 signs are posted throughout the facility in the bathrooms, kitchen, and hallway to promote handwashing, cough/sneeze etiquette, and physical distancing.
· Facility has no designated isolation room as residents have private rooms that can serve that purpose.
· Five (5) resident rooms, common areas, bathrooms, and outdoor physical plant was inspected.
· All client rooms were not equipped with alcohol-based hand sanitizer but available throughout the facility
· Five (5) centrally stored client medication records were reviewed.
· Staff responsible for direct care and supervision were observed wearing masks.
· Clients were not present during visit..
· Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
· A posted Emergency Disaster Plan was observed.
· PPE's were observed.
· Staff and resident files were not reviewed during today's visit.
· Deficiencies cited (see 809D for details)

Exit interview was conducted with Assistant Administrator Fransica Chamu-Nesto. A copy of the report was provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2022
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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Document Has Been Signed on 05/17/2022 12:36 PM - It Cannot Be Edited


Created By: Alberto Lopez On 05/17/2022 at 12:17 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: KOCH-VAGTHOL'S METABOLIC RESIDENTIAL CENTER
FACILITY NUMBER: 198600312

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Facility screens shall be in good reapir at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, LPAs and administrator observed window screen in disrepair on south side of home. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2022
Plan of Correction
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Administrator will purchase window screen and send photo to LPA by POC date.
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:Stefanie Coronel
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022


LIC809 (FAS) - (06/04)
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