198600346-1-24-2025-28-AS-THEA-DD8VLS-20250124153226

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600346
Report Date: 01/24/2025
Date Signed: 01/24/2025 03:33:16 PM

Document Has Been Signed on 01/24/2025 03:33 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:	FOSTER AVENUE HOME		FACILITY NUMBER:	198600346
ADMINISTRATOR/ DIRECTOR:	EILEEN CORREOS		FACILITY TYPE:	735
ADDRESS:	10953 FOSTER AVENUE		TELEPHONE:	(562) 627-9612
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY: 4		CENSUS: 4	DATE:	01/24/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:53 PM
MET WITH:	Rechele Green - Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:48 PM

NARRATIVE

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Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Administrator Rechele Green and explained the purpose for today’s visit, shortly after Program Director Eileen Correos arrived to assist with visit. The facility is licensed to serve 4 Ambulatory Only adults ages 18-59 years. The facility currently has 4 clients that are serviced through Harbor Regional Center.

The facility is a single-story home located in a residential area in Norwalk, Ca. A tour of the facility includes: 4 client bedrooms, 2 full bathrooms (1 bath is in private client room), living room, dining area, kitchen, office area, detached garage with laundry, front yard and back yard.

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

Infection Control: Facility has sufficient PPE supplies and the required Infection Control Plan.
Physical Plant & Environment Safety: LPA toured facility, clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested in the client bathrooms and was outside the required range of 105-120 degrees F, water measured between 128.1-132.2 degrees F, details will be cited on the 809-D. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked cabinet, however, during tour LPA observed cleaning supplies stored in an unlocked cabinet under bathroom sink within clients private bath, details will be cited on the 809-D. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged.
Operational Requirements: Staff have proper training to meet the needs of the clients in care. Facility has an activity area furnished for outdoor use. Last fire/earthquake drill was conducted on 12/5/24.
(Continued on LIC809-C)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025

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: FOSTER AVENUE HOME	FACILITY NUMBER: 198600346
	VISIT DATE: 01/24/2025

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Staffing: There appears to be sufficient staffing at all times in the facility.
Personnel Records-Training: Staff files are maintained in a secure location. LPA reviewed 4 staff files during today’s visit, files reviewed contained the following: Criminal Background Clearance, First-Aid/CPR/AED/CPI and sufficient on-going training. Rechele Green maintains a valid certificate that expires on 10/22/2026.
Client Rights-Information: Facility provides telephone landline and internet for the clients. Client rights posters and reporting posters are displayed within the facility.
Client Records-Incident Reports: Client files are maintained in a secured location and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. LPA reviewed 4 client files with no issues.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Service: Staff designated to administer medication have the proper annual training on file. Medication is properly labeled and are centrally stored in a locked cabinet and are in their original containers. LPA reviewed 4 client medications with no issues.
Incidental Medical & Dental: All training is documented in the facility personnel files.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Facility maintains documentation of the required emergency drills.
Emergency Intervention: Clients at this facility do not need the use of restraints or de-escalation techniques.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during todays visit will be documented on the 809D.

Exit interview was held and a copy of the report and appeal rights will be emailed to Program Director Eileen Correos at levienhomes@hotmail.com.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/24/2025 03:33 PM - It Cannot Be Edited

Created By: Tena Herrera On 01/24/2025 at 03:09 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: FOSTER AVENUE HOME	FACILITY NUMBER: 198600346
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(g)

Building and 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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as during tour LPA observed cleaning disinfectants under the bathroom sink within clients private bath (client does not have a doctors clearance stating client is able to handle disinfectants, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/25/2025
	Plan of Correction
1 2 3 4	Administrator removed cleaning supplies from bathroom and stored in a locked cabinet during visit. POC cleared during visit.

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as LPA measured water temperature within clients private bath with a reading of 132.2 degrees F and main bath which measured at 128.1, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/25/2025
	Plan of Correction
1 2 3 4	Administrator was able to lower water temperature during visit. Administraor/Licensee to monitor water temperature for the next 3 days begining 1/25/25 and ending 1/27/25, water is to be tested 3x a day (morning, afternoon, evening) and mesurements must be within the required range, a log must be created with all information and emailed to LPA by 1/28/25. tena.herrera@dss.ca.gov

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:

Tena Herrera

LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025

LIC809 (FAS) - (06/04)

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