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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600581
Report Date: 07/15/2024
Date Signed: 07/15/2024 03:52:56 PM


Document Has Been Signed on 07/15/2024 03:52 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:HOMES FOR LIFE FOUNDATION-HFL CEDAR STREET HOMEFACILITY NUMBER:
198600581
ADMINISTRATOR:VIDA ANDRADEFACILITY TYPE:
735
ADDRESS:11401 BLOOMFIELD, BLDG.305-307TELEPHONE:
(562) 207-9660
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY:38CENSUS: 30DATE:
07/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Administrator Vida Andrade TIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met Manager Nicholas Novella and the purpose of the visit was discussed. Administrator Vida Andrade arrived shortly after. The facility is approved for serve Adults 18-59 years old only and ambulatory only.
The following twelve (12) tool domains were completed:
1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility still encourages hand washing. The facility has an Infection Control Plan. LPA collected a copy.

2. Physical Plant and Environmental Safety: The facility is a two-story building in a large private lot. The facility includes: Community Lounge, Dining Room, Kitchen, Staff Lounge / Medication Room, Laundry Room, (4) offices, and approx. (10) storage rooms. The facility contains a total of (23) bedrooms, about (8) bathrooms upstairs and downstairs total . Bathrooms observed have running hot water, hot was temperature measured between 105.7 and 112 degrees F which is within the Title 22 regulation. LPA inspected random resident bedrooms: # 111, #127, #128, #203, #209, #224 and #229. Each bedroom had required beds for each client, chairs, night stands, dressers and required bed linen and sufficient lighting and closet space. Facility has call systems in client room. LPA observed extra linen and towels located on the 2nd floor. All the appliances in the kitchen are working properly. The facility has a covered patio area for shade (Gazebo) used for outside activities. No large bodies of water observed. Pathways, hallways and stairs are free of obstructions. No elevator located in the facility. LPA inspected the carbon monoxide detectors which were operable. Smoke detectors throughout the facility are hard wired through the Fire Department of Norwalk, and facility has a fire alarm pull systems in place. There are fire extinguishers throughout the facility and they are up-to-date, charged and serviced. Last Fire Drill conducted on: 6/24/2024.

3. Operational Requirements: The facility is only approved for ambulatory only. Currently all (30) clients are ambulatory. Fire drills conducted monthly. The facility has a shaded area for clients to use.
******Continued on LIC 809-C********
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 07/15/2024 03:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: HOMES FOR LIFE FOUNDATION-HFL CEDAR STREET HOME
FACILITY NUMBER: 198600581

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as (1) of (6) Client medications for Pantroprazole SOD DR 20mg that was reviewed had not been popped out and was skipped over for one day with no documentation to reason why which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2024
Plan of Correction
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Facility/Administrator to schedule in service training regarding medications management. LPA to be informed of training by POC due date and then provided proof of training once completed.
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: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HOMES FOR LIFE FOUNDATION-HFL CEDAR STREET HOME
FACILITY NUMBER: 198600581
VISIT DATE: 07/15/2024
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4.Staffing: The facility has sufficient staffing to provide care and supervision. Sufficient overnight staff observed on schedule. Training's for staff supervision protocols observed.

5.Personnel Records-Training: All the facility staff files are maintained in the facility. The Administrator Vida Andrade's certificate is currently pending renewal with the department. Administrator has required completed training's on file. LPA reviewed five (5) Staff files. Required documents observed on file for all.

6.Client's Right: The facility does not have any client with postural support at the present time. The facility does serve adults has internet service shall provide at least one access device.

7.Client's Records-Incident Reports: All the clients files are maintained in the facility. LPA reviewed six (6) clients files and they all have the required documents which are included: admission agreement, functional capabilities assessment, updated physician report, Individual Personalized Plan (IPP), ambulatory status and medication list ..etc

8.Food Service: Facility has sufficient food supply is stored in the kitchen and the garage consisting of: 2-day perishables, 7-day non-perishables. The refrigerator is maintained in the required temperature. All the food are stored probably.

9. Health Related Services: All the clients medication are centrally stored and inaccessible to clients in care. LPA inspected five (5) client medications. A medication error was observed and addressed.

10. Incidental Medical Services: The facility currently does not have any clients with any prohibited health condition or restricted health condition.

11. Disaster Preparedness: The facility has an emergency and disaster plan in place. The facility has two appropriate temporary shelter location. Client emergency files are available when needed.

12. Emergency Intervention: The facility is not using any restraint in the facility.

Per Title 22 Regulations, a deficiency us being cited. Please see attached LIC 809-D page. Exit interview conducted, a copy of the report and appeal rights were discussed and provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3