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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600558
Report Date: 04/03/2023
Date Signed: 04/03/2023 01:46:54 PM

Document Has Been Signed on 04/03/2023 01:46 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PALS EINDELIJK EL MONTEFACILITY NUMBER:
198600558
ADMINISTRATOR:GLORIA GALLEGOSFACILITY TYPE:
775
ADDRESS:11645 MCBEAN DR.TELEPHONE:
(626) 279-1064
CITY:EL MONTESTATE: CAZIP CODE:
91732
CAPACITY: 60CENSUS: 37DATE:
04/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Gloria GallegosTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit and was greeted by Program Manager Zeke Meza and explained the reason for the visit. The purpose of the visit is to complete the required inspection. Shortly thereafter Administrator Gloria Gallegos arrived.
LPA Trueman toured the facility along with Program Manager Zeke Meza today 04/03/2023 at 9:30 AM and the following was observed:
Facility contains : Front office, conference room, supervisor office, manager office, 2 activity rooms , 6 programming rooms, storage room, infirmary, 4 restrooms each with sink and toilet and a kitchen area.
Annual Inspection includes the following Domains:
Infection Control, Physical Plant and Environment Safety, Operational Requirements, Staffing, Personnel Records- Training, Client Rights Information, Client rights- Incident Reports, Food Service, Health Related Services, Incidental Medical Services, Disaster Preparedness, and Emergency Intervention.
Interviews were conducted with 3 clients and 3 staff. 5 client files and 5 staff files were reviewed
All staff were cleared and associated.
Medication was administered per physician's directions for 1 client at the Program.
Signage for hand washing and proper sanitizing were posted. Staff have been trained in hand washing.
Direct care staff had a minimum of 8 hours of annual training,
Licensee maintained an individual admission agreement for each client.
Fire Clearance has been maintained. Hot water temperature was measured between 105F and 120 F. meeting regulations.
Each client has personal rights free from corporal or unusual punishment, infliction of pain, humiliation, ridicule, coercion, threats, mental abuse, or other actions of a punitive nature.
Program site was clean, safe, sanitary, and in good repair at all times for the safety and well being of clients, employees and visitors.
Program did not have 1 or more carbon monoxide detectors present in the facility.
Deficiency cited on 809 D. Exit interview conducted.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE: DATE: 04/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2023
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 04/03/2023 01:46 PM - It Cannot Be Edited


Created By: Glenn Trueman On 04/03/2023 at 01:20 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: PALS EINDELIJK EL MONTE
FACILITY NUMBER: 198600558

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above with the Program not having 1 or more carbon monoxide detectors present in the facility. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/06/2023
Plan of Correction
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Facility to ensure that one or more carbon monoxide detectors be in the facility and submit proof to LPA by POC due date.
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:Glenn Trueman
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2023


LIC809 (FAS) - (06/04)
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