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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600426
Report Date: 05/02/2024
Date Signed: 05/02/2024 02:53:34 PM

Document Has Been Signed on 05/02/2024 02:53 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:C-H #5 RESIDENTIAL FACILITYFACILITY NUMBER:
198600426
ADMINISTRATOR/
DIRECTOR:		JEFFERSON, REBEKAHFACILITY TYPE:
735
ADDRESS:14750 WIEMER AVETELEPHONE:
(562) 634-4151
CITY:PARAMOUNTSTATE: CAZIP CODE:
90723
CAPACITY: 3CENSUS: 1DATE:
05/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Rebekah Jefferson (Administrator)TIME VISIT/
INSPECTION COMPLETED:
03:08 PM
NARRATIVE
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility using the CARE Tool. LPA Mora met with Rebekah Jefferson (Administrator) and explained the reason for the visit. The facility is licensed to serve 3 developmentally disabled adults ages 18 thru 59 years old, ambulatory only. The facility is operating within the scope of its license

A tour of the single-story facility included the living room, kitchen, dining area, 3 client bedrooms, 2 bathrooms, laundry area, recreational room, front yard, backyard, and attached garage. LPA Mora conducted a tour of the facility and observed the following: sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables were observed in the kitchen and the garage refrigerators. Sharps, chemical and cleaning solutions are kept locked under the kitchen sink. There was 2 cleaning solutions (Ajax and Cloralen) under the sink of bathroom #1 and were accessible. The First Aid kit is kept in a living room cabinet and it is fully stocked with all required items including a current manual. Clean towels and extra clean linen were observed in a hallway cabinet. Dining and living room have sufficient lighting and sitting area. Medications are kept locked in a laundry room cabinet. Staff files are kept in the medication cabinet. Client files are kept in a cabinet near the living room. All bedrooms have all required furniture, lighting, and bedding. Client 1 (C1) mattress pad is torn and dirty. All bathrooms were observed with shower mats. The water temperature was tested in both bathrooms, and measured at 139.6 degrees F, which is not within the required 105-120 degrees F. A fire extinguisher was observed in the kitchen and it is fully charged. Smoke detectors were observed throughout the facility and in each room, and were operable during the visit. There is a carbon monoxide in the kitchen and was operable during the visit. The front yard and backyard are clean. There is a shaded area with seating in the backyard. No bodies of water were observed at the facility. Passageways and exits are free of obstruction. (Continued to LIC 809-C)
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: C-H #5 RESIDENTIAL FACILITY
FACILITY NUMBER: 198600426
VISIT DATE: 05/02/2024
NARRATIVE
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LPA reviewed medication for 1 client and observed that medications are documented properly and given as prescribed. LPA reviewed files for 1 client and 5 staff. C1 does not have a physician report on file and he was admitted to the facility on 12/01/2023. LPA observed administrator certificate for Rebekah Jefferson - 6014869735 with an expiration date of 03/31/2024 and her renewal is pending as of 02/27/2024. During this annual, LPA Mora was made aware that Client 2 (C2) passed away on 04/17/2024. A death report and incident report of the incident that led to C2 being hospitalized on 04/14/2024 were not submitted to the Community Care Licensing Division (Refer to LIC 809 - Case Management dated 05/02/2024 for further details).

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were deficiencies observed during the visit (Refer to LIC 809-D). Exit interview held and a copy of the report were provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024
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Page: 2 of 6
Document Has Been Signed on 05/02/2024 02:53 PM - It Cannot Be Edited


Created By: Luis Mora On 05/02/2024 at 01:26 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: C-H #5 RESIDENTIAL FACILITY
FACILITY NUMBER: 198600426

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80061(b)(1)(B)
Reporting Requirements
(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. (1) Events reported shall include the following: (B) In a residential facility, death of any client as a result of injury, abuse, or other than natural causes, regardless of where the death occurred. This includes a death that occurred outside the facility such as at a day program, workshop, job, hospital, en route to or from a hospital, or visiting away from the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. Client 2 passed away on 04/17/2024 and no death report was submitted to the Community Care Licensing Division (CCLD).
POC Due Date: 05/09/2024
Plan of Correction
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Licensee is to comply with Title 22 Section 80061 at all times. Additionally, Licensee will submit a Death Report (LIC 624A) and conduct a staff training regarding Title 22 80061 reporting requirements and submit proof of training to CCLD by 05/09/2024.

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:Wei Siew Ho
LICENSING EVALUATOR NAME:Luis Mora
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2024


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Document Has Been Signed on 05/02/2024 02:53 PM - It Cannot Be Edited


Created By: Luis Mora On 05/02/2024 at 01:31 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: C-H #5 RESIDENTIAL FACILITY
FACILITY NUMBER: 198600426

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80061(b)(1)(D)
Reporting Requirements
(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. (1) Events reported shall include the following: (D) Any injury to any client which requires medical treatment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. Client 2 (C2) was taken to the hospital on 04/14/2024 due to a fall at a skilled nursing that eventually led to C2 passing away. This incident was not reported to the Community Care Licensing Division.
POC Due Date: 05/09/2024
Plan of Correction
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Licensee is to comply with Title 22 Section 80061 at all times. Additionally, Licensee will submit a Unusual Incident/Injury Report (LIC 624) and conduct a staff training regarding Title 22 80061 reporting requirements and submit proof of training to CCLD by 05/09/2024.
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:Wei Siew Ho
LICENSING EVALUATOR NAME:Luis Mora
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/02/2024 02:53 PM - It Cannot Be Edited


Created By: Luis Mora On 05/02/2024 at 02:10 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: C-H #5 RESIDENTIAL FACILITY
FACILITY NUMBER: 198600426

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2024

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
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Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. A bottle of Ajax and Cloralen were under bathroom #1's sink and were not locked.
POC Due Date: 05/03/2024
Plan of Correction
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Licensee is to comply with Title 22 Section 80087 at all times and removed the cleaning solutions from the bathroom and locked them. Additionally, Licensee will conduct a staff training regarding Title 22 80087 and submit proof of training to CCLD by 05/09/2024.
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
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Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. Water temperature in the bathrooms measured at 139.6 degrees F.
POC Due Date: 05/03/2024
Plan of Correction
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Licensee is to comply with Title 22 Section 80088 at all times and will lower the water temperature within 105 - 120 degrees F. Additionally, Licensee will measure the water temperature for a week and document the water temperature and submit this documentation to CCLD by 05/09/2024.
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:Wei Siew Ho
LICENSING EVALUATOR NAME:Luis Mora
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 05/02/2024 02:53 PM - It Cannot Be Edited


Created By: Luis Mora On 05/02/2024 at 02:10 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: C-H #5 RESIDENTIAL FACILITY
FACILITY NUMBER: 198600426

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(4)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (4) Clean linen in good repair, including lightweight, warm blankets and bedspreads; top and bottom bed sheets; pillow cases; mattress pads; rubber or plastic sheeting, when necessary; and bath towels, hand towels and wash cloths.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. Client 1 (C1) mattress pad was torn and dirty.
POC Due Date: 05/09/2024
Plan of Correction
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Licensee is to comply with Title 22 Section 85088 at all times and provide C1 with a clean mattress pad in good repair. Additionally, Licensee will submit a picture of the new mattress pad on the bed to CCLD by 05/09/2024.
Type B
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. Client 1 (C1) file did not have a physician report.
POC Due Date: 05/16/2024
Plan of Correction
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Licensee is to comply with Title 22 Section 80069 at all times. Additionally, Licensee will obtain a physician report for C1 and submit a copy to CCLD by 05/16/2024.
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:Wei Siew Ho
LICENSING EVALUATOR NAME:Luis Mora
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2024


LIC809 (FAS) - (06/04)
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