198600336-3-10-2023-28-AS-EIRA-CPSSHR-20230310125359

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600336
Report Date: 03/10/2023
Date Signed: 03/10/2023 12:54:31 PM

Document Has Been Signed on 03/10/2023 12:54 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:	CONWELL RESIDENTIAL FACILITY		FACILITY NUMBER:	198600336
ADMINISTRATOR:	REYES, MANUELITA V.		FACILITY TYPE:	735
ADDRESS:	4656 NORTH CONWELL AVENUE		TELEPHONE:	(626) 332-0190
CITY:	COVINA	STATE: CA	ZIP CODE:	91722
CAPACITY: 6		CENSUS: 5	DATE:	03/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Rebecca Viloria and Manuelita Reyes		TIME COMPLETED:	12:45 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) Elizabeth Irra conducted the required annual inspection. LPA was allowed entry by Rebecca Viloria. Facility Administrator, Manuelita Reyes, arrived at approximately 8:45 AM to assist with this inspection. LPA explained the purpose of today's visit. The facility is licensed for mentally ill clients ages 18-59. The fire clearance is approved for (6) ambulatory clients. 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 and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has sufficient PPE supplies, has an Infection Control Plan and Mitigation Plan. Facility has COVID-19 signage posted throughout the facility. Bathrooms have hand washing signs, soap and paper towels. Per Facility Administrator all (5) clients have COVID-19 vaccines including boosters. Per Facility Administrator all staff also have the COVID-19 vaccines including boosters. Facility Administrator is adhering to infection control requirements. Operational Requirements: The fire clearance is approved for (6) ambulatory clients. Last Fire Drill and Earthquake Drill: 01/20/2023. Per Facility Administrator, these drills are completed every (6) months. Facility Administrator is adhering to operational requirements. Refer to LIC 809C for the continuation of this report.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023

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: CONWELL RESIDENTIAL FACILITY	FACILITY NUMBER: 198600336
	VISIT DATE: 03/10/2023

NARRATIVE

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Physical Plant & Environment Safety: This facility consists of (4) bed rooms (1 of which is a staff bedroom), (2) bathrooms (1 of which is located inside the staff's bedroom), living room, kitchen, dinning area, back patio (shaded area) and attached garage. Smoke alarms were tested and operable. Fire extinguisher appeared to be full. Carbon monoxide tested and operable. 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 111.3* in the kitchen and 112* in the bathrooms.

Staffing: There is sufficient staffing at the facility. Administrator Certificate for Manuelita Reyes expires on 07/28/2023 and HIV Training Certificate is dated 02/18/2023. 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 staff files for Facility Administrator, S-1 and S-2. Staff have current CPR/first aid training and 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-Information: Client personal rights and House Rules are posted. Per Facility Administrator, facility provides wi-fi services to all clients which clients utilize through their personal cell phone.

Client Records-Incident Reports: LPA reviewed Client files for C-1 through C-5. Client files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment, Appraisal Needs and Services Plan, Functional Capabilities Assessment, Mental Health Intake Assessment, Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights.

*** Refer to LIC 809C for the continuation of this report***

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023

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: CONWELL RESIDENTIAL FACILITY	FACILITY NUMBER: 198600336
	VISIT DATE: 03/10/2023

NARRATIVE

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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 no clients with special diets residing at this facility. Pesticides and cleaning supplies are kept away from the food preparation areas (locked under the kitchen sink). 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 C-1 through C-5. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubbled packed.

Incidental Medical Services: Per Facility Administrator, there are no clients at this home with incidental medical services nor have a restricted health condition.

Disaster Preparedness: The facility has an Emergency Disaster Plan readily accessible.

Emergrency Intervention : Not-Applicable.

No deficiencies noted. Exit interview, appeals rights and a copy of this report was provided to Manuelita Reyes.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023

LIC809 (FAS) - (06/04)

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