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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600312
Report Date: 09/26/2023
Date Signed: 09/26/2023 05:08:13 PM

Document Has Been Signed on 09/26/2023 05:08 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
Lookup Error,
, CA
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: 5CENSUS: 5DATE:
09/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Francisca Chamu-Nestor - AdministratorTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced required 1-yr inspection. LPA was allowed entry by Emmeline Baldoza, DIrect Support Professional I (DSP I) and explained the purpose of the visit. At 1:00pm, Francisca Chamu-Nestor, Administrator, arrived and assisted LPA with the inspection. The facility is a Specialized home and licensed for (5) non-ambulatory clients age 18 through 59. All clients residing at this facility receive case management services provided by Frank D. Lanterman Regional Center.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station and PPE supplies located near the front door. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Facility has COVID-19 signage posted throughout the facility. Bathrooms have hand washing signs, soap and paper towels. Staff are adhering to infection control requirements
Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan and submitted to CCL. Liability Insurance policy in the amount of $1,000,000.00 each occurrence and #3,000,000.00 in the total annual aggregate is valid and will expire on 7/13/2024. Surety Bond (Western Surety Company)is in effect and in force with bond amount of $10,000. The fire clearance is approved for (5) non-ambulatory clients. Fire drill was last conducted on 08/13/2023 and Earthquake drill was last conducted on 7/16/2023.
Physical Plant & Environment Safety: This facility consists of (5) client bedrooms and (1) staff room, (2) client bathrooms, (1) staff bathroom, living room, relaxation/lounge, kitchen, dining area, backyard patio area, detached office and detached garage. Smoke alarms and carbon monoxide were tested and operable. Total of (4) fire extinguishers appeared to be full and were last serviced on 10/20/2022. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. There are no firearms or weapons stored at the facility. Hot water supply measured 114.8 deg F in bathroom #1, 115.3 deg F in bathroom #2 and 112.1 deg F in bathroom #3, which were all within Title 22 Regulations. 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.

*****Refer to LIC 809C for the continuation of this report.*****
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2023
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
Lookup Error,
, CA
FACILITY NAME: KOCH-VAGTHOL'S METABOLIC RESIDENTIAL CENTER
FACILITY NUMBER: 198600312
VISIT DATE: 09/26/2023
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Staffing: There is sufficient staffing at the facility. A total of ten (10) staff members plus the Administrator provide care and supervision to the clients. Administrator Certificate for Francisca Chamu-Nestor expires on 10/08/2023 and HIV/Infectious Disease Training Certificate was completed on 9/13/2023. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.
Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed three (3) staff files, for Facility Administrator, S1 and S2. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Administrator certificate is valid and expiring on 10/08/2023. Staff have sufficient on-going training that meets the annual requirement. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting, Client Rights and Zero Tolerance Policy.
Client Rights-Information: Client personal rights are posted. Facility provides internet services to all clients and have access to the facility phone. None of the clients have their own personal cell phones. Administrator stated that (1) out of (5) clients has her own tablet. LPA attempted to conduct client interviews but (5) were in the Day Program and all are non verbal.
Client Records-Incident Reports: LPA reviewed Client files for C1-C3. Client files are maintained at the facility. Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment, Individual Program Plan (IPP), Behavioral Reports, Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights observed.
Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The food is properly stored in the refrigerator (clean and well maintained). There are (4) clients with special Phenylketonuria (PKU) diets residing at this facility. Pesticides and cleaning supplies are kept away from the food preparation areas (locked inside the laundry closet). Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.
Health Related Services: The medications are centrally stored and in their original containers. LPA reviewed medication for C1 through C3. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Some medications are bubbled packed and some are in regular pill bottles.
Incidental Medical Services: Administrator stated that there are no clients at this home with incidental medical services nor have a restricted health condition.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan.
Emergency Intervention: Not-Applicable.


No deficiencies cited. Exit interview and a copy of this report was provided to Francisca Chamu-Nestor, Administrator.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023
LIC809 (FAS) - (06/04)
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