<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600611
Report Date: 02/07/2022
Date Signed: 02/07/2022 01:31:05 PM

Document Has Been Signed on 02/07/2022 01:31 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:ABRAJANO GROUP HOMEFACILITY NUMBER:
198600611
ADMINISTRATOR:ABRAJANO, JOSEPHFACILITY TYPE:
735
ADDRESS:5953 E. GALLANT ST.TELEPHONE:
(562) 928-1927
CITY:BELL GARDENSSTATE: CAZIP CODE:
90201
CAPACITY: 12CENSUS: 5DATE:
02/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Staff Consolacion Villanueva and
Administrator Gary Abrajano		TIME COMPLETED:
01:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
At 9:10 am Licensing Program Analysts (LPA) Nune Margaryan arrived at this facility unannounced to conduct an annual inspection visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures, reviewed client files, and reviewed staff fingerprint clearances. Facility submitted a mitigation plan and the plan was approved on 4/15/2021.
Upon arrival, LPA met with Staff Consolacion Villanueva who assisted with the visit. At the letter time Administrator Gary Abrajano arrived. The purpose of visit was explained.
There is only one entrance being utilized at the facility, all required posters were posted at the entrance. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing mask upon entrance and during visit.

Abrajano Group Home is an adult residential home licensed to serve a total of twelve (12) Developmentally Disable Adults between the ages of 18 to 59. Currently there are five (5) clients in placement from South Central Los Angeles Regional Center. Abrajano Group Home is a single story home/facility with an attached home/facility located in the back. The front house consist of: living room, kitchen, dining room, three (3) bathrooms, three bedrooms (1 staff bedroom), office. The back house consist of: four bedrooms (1 staff bedroom), two (2) bathrooms, attached garage with laundry area, patio with chairs.

LPA toured the facility at 9:20 am. Areas inspected included: common living spaces, clients bedrooms, bathrooms, kitchen, garage, and backyard. Facility was free of odor. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present in the facility.

Continue 809C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2022
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
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: ABRAJANO GROUP HOME
FACILITY NUMBER: 198600611
VISIT DATE: 02/07/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The kitchen was observed for the ability to prepare and serve food. Appliances in the kitchen were functional but not clean. The stove was dirty with oil stains all over. Kitchen cabinets also needed cleaning. The facility looked like it needed to be deep cleaned, it was noted to be dusty all around.
LPA observed an appropriate food supply of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days. All sharp objects and knives are stored in the kitchen cabinet making it inaccessible to residents. All chemicals and cleaning solutions are observed to be locked and inaccessible to the residents.
Clients rooms were observed and had the required furniture and furnishings. The bathrooms are operational w/grab bars and non-skid surface/mats in place. The hot water temperature was tested throughout the facility and maintained within the required range of 105-120*F. LPA observed that in the bathroom located in the back house / bedroom #4 , hand washing sink was not draining the water.

LPA observed clients' centrally stored medications ( bubble pack) with their medication administration records. Designated centrally stored medication area was locked and located in a dining room. First aid kit is complete. LPA inspected smoke detectors. All smoke detectors are operating properly. All fire extinguishers are fully charged.

There are deficiencies observed during today's visit and are cited under the California Code of Regulations Title 22 on the LIC 809D.


Exit interview was conducted. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/07/2022 01:31 PM - It Cannot Be Edited


Created By: Nune Margaryan On 02/07/2022 at 12:57 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: ABRAJANO GROUP HOME
FACILITY NUMBER: 198600611

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Buildings and Grounds. The facility shall be kept clean, sanitary and in good repair at all times. This requirement is not met as evidenced by:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation the stove in the kitchen was dirty with oil stains all over. Kitchen cabinets also needed cleaning. The facility looked like it needed to be deep cleaned, it was noted to be dusty all around.
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.
POC Due Date: 02/07/2022
Plan of Correction
1
2
3
4
Deficiencies were corrected at the time of visit. no further action needed.
Type B
Section Cited
CCR
80088(e)(3)
FIXTURES, FURNITURE EQUIPMENT AND SUPPLIES: Toilets, hand washing and bathing facilities shall be maintained in safe and sanitary operating condition, and additional equipment, aids, and/or conveniences shall be provided for physically handicapped clients who need such items.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation LPA noticed that in the bathroom located in the back house / bedroom #4 , hand washing sink was not draining the water. 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.
POC Due Date: 02/07/2022
Plan of Correction
1
2
3
4
Administrator will ensure to have the hand washing sink in the bathroom repaired. At the time of visit Administrator fixed the sink and no further action needed.
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:Nune Margaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2022


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