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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600314
Report Date: 02/02/2023
Date Signed: 02/02/2023 08:09:39 PM

Document Has Been Signed on 02/02/2023 08:09 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:HOUSE ON GARO, THEFACILITY NUMBER:
198600314
ADMINISTRATOR:STALLCUP-DOBRENEN, CARRIEFACILITY TYPE:
735
ADDRESS:15463 GARO STREETTELEPHONE:
(626) 369-0099
CITY:HACIENDA HEIGHTSSTATE: CAZIP CODE:
91745
CAPACITY: 6CENSUS: 4DATE:
02/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:46 PM
MET WITH:Nicholas Baez TIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Christine Wong and Tena Herrera conducted an annual required visit. LPA met with Staff Lorenzo Tii and explained the reason for the visit. Shortly after, the House Manager Nicholas Baez arrived and assisted with the visit. LPA's used the infection control tool to evaluate the facility. LPA's observed the facility plant, COVID-19 procedures, reviewed clients' medications, observed food supply, and reviewed clients and staff files.

The facility is a single story house and located in a residential neighborhood area. The facility includes: Living room, dining area, kitchen, four clients bedrooms, two clients bathrooms and an attached garage. All four clients bedrooms were toured. Bedroom#1 and #2 has one bed, one chair, one drawer, required furniture and bed linen and sufficient lighting and closet space. Bedroom #3 and #4 has two beds, two drawers, and two chairs, required furniture and bed linen, sufficient lighting and closet space. All two bathrooms were toured. They were clean, sanitary and in a good working condition. LPAs measured the hot water temperature at both bathrooms were tested between 109.5 to 110,8 degrees F which is within Title 22 regulations. The refrigerator and the pantry has two days perishable and seven days non perishable food supply. All the sharp knives and utensils are locked in the hallway storage room. All the appliances are clean and working probably in the kitchen. LPAs also observed two ant and roach killer spray in the kitchen cabinet which is not locked and the detergent on the buffet table near the kitchen. The common area such as living room and dining area are clean and have the required furniture. The front and back yard are maintained well and they have a shaded area with tables and chairs for client utilize.

LPAs reviewed 4 clients files to confirm emergency contact is updated. LPAs also reviewed 2 staff files to confirm health screenings and fingerprint clearances. LPA reviewed all four clients medication and all seemed accurate and updated.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2023
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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Document Has Been Signed on 02/02/2023 08:09 PM - It Cannot Be Edited


Created By: Christine Wong On 02/02/2023 at 01:51 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: HOUSE ON GARO, THE
FACILITY NUMBER: 198600314

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
80087 Buildings ang Grounds (g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs obsevation, LPAs obseved two ant and roach spray in the kitchen cabinet which was unlocked and the detergent on the buffet table near the kitchen which posed an immediate risk to clients in care.
POC Due Date: 02/03/2023
Plan of Correction
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The administrator will ensure the disinfectants, cleaning solutions, poisions, firearms and other items shall be stored where inaccessible to clients. The administrator will locked the items right away and send proof to LPA By POC due date

***** House manger throw away the spray and locked the detergent back in garage. ******
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:David Sicairos
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2023


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: HOUSE ON GARO, THE
FACILITY NUMBER: 198600314
VISIT DATE: 02/02/2023
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Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, the staff would disinfect the facility twice daily, and PPE supplies are stored for 30 days.

The deficiencies cited are documented on the attached 809D. A copy of the report and appeal rights will be provided to house manager.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023
LIC809 (FAS) - (06/04)
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