198600410-9-6-2024-28-AS-DKOI-D8UQWZ-20240906123248

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600410
Report Date: 09/06/2024
Date Signed: 09/06/2024 12:33:32 PM

Document Has Been Signed on 09/06/2024 12:33 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	CASA BONITA		FACILITY NUMBER:	198600410
ADMINISTRATOR/ DIRECTOR:	KARINA SOTO		FACILITY TYPE:	735
ADDRESS:	13945 CLOSE STREET		TELEPHONE:	(562) 941-2890
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90605
CAPACITY: 6		CENSUS: 5	DATE:	09/06/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:20 AM
MET WITH:	Edward Ventura, Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:45 PM

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Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Annual Required Visit on 09/06/2024.. LPA were met by Staff #1 (S1) and explained the purpose of the visit. S1 assisted in tour of facility. Administrator Edward Ventura arrived shortly after to the facility and was explained the purpose of the visit. The facility has a fire clearance approved for six (6) developmentally disabled adults, four (4) nonambulatory and two (2) ambulatory clients, with restricted health conditions. All clients receive services from East Los Angeles Regional Center. LPA observed Personnel Report and Resident Roster. The facility currently has 5 clients. The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention.

Infection Control:

· Infection control practices and Personal Protective Equipment (PPEs) were observed.

· LPA observed that the facility has an infection control plan in place.

Physical Plant/Environment Safety:

· LPA conducted a tour of the facility with S1 and observed the following:

The facility is a single-story building in a residential area, with a kitchen, dining room, living
room, two (2) private bedrooms, two (2) client shared bedroom, and the backyard with shaded area and a garage.
· All passageways, walkways, driveway, steps and patio are free from obstructions. The front, back and side areas of the house are free of hazards.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CASA BONITA	FACILITY NUMBER: 198600410
	VISIT DATE: 09/06/2024

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· Smoke/carbon monoxide detectors are tested and in working condition.
· Cleaning supplies are kept locked in the cabinet in the kitchen away from food supplies.
· Sharps are kept locked in the cabinet in the kitchen.
· Shared client bathrooms were observed to be clean and contained soap and paper towels.
· Restroom #1 (R1) had a hot water temperature reading measured at 105.0 Degrees F and Restroom #2 (R2) measured at 105.0 Degrees F which meets the required 105 Degrees F – 120 Degrees F per Title 22 Regulations.

Operational Requirements:
· The facility has a fire clearance approved for six (6) developmentally disabled adults, four (4)
nonambulatory and two (2) ambulatory clients, with restricted health conditions.
Staffing:

· A total of 12 (twelve) full-time staff members provide care and supervision to the clients.

Personnel Records / Staff Training:

· Administrator’s certificate is effective to 01/09/2026.

· LPA observed Administrator HIV & TB training on file.
· Five (5) staff files were reviewed for criminal background clearance and training.
· Personnel records have Health/Tuberculosis (TB) screenings, Employee Rights, certifications, and 1st Aid/CPR training.
· Facility has per regulation staff training in file.

Client Rights/Information:

· Physician orders were reviewed in client files.
· Phone and Internet access is available for the clients use.

Client Records/Incident Reports:
· Five (5) client files were reviewed containing Admission Agreements, Physician’s Report, TB clearance, Individual Program Plan, Personal Rights, Functional Capabilities Assessments, Medication Records, and Personal and Incidental (P & I) money were reviewed.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CASA BONITA	FACILITY NUMBER: 198600410
	VISIT DATE: 09/06/2024

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Food Services:
· The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.

Health Related Services:
· Clients are assisted with self-administration of prescription and non-prescription medications.

· Five (5) centrally stored resident medication records were reviewed.

· First Aid Kit was reviewed and has required items.
· LPA observed medication located in closet at the dining room is locked and inaccessible to residents. · LPA reviewed five (5) out of five (5) client medications and Medication Administration Record (MAR).

Incidental Medical and Dental:
· All clients have a current Individual Program Plan, and COVID-19 vaccination cards on file.

Disaster Preparedness, and Emergency Intervention:
· LPA observed Emergency Disaster Plan LIC 610D containing emergency evacuation information.

· An emergency drill was last documented on 08/27/2024.

Emergency Intervention:
· No manual restraints or seclusion are used with clients in care.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided to the Administrator, Edward Ventura.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

LIC809 (FAS) - (06/04)

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