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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600611
Report Date: 02/15/2024
Date Signed: 02/15/2024 11:34:24 AM

Document Has Been Signed on 02/15/2024 11:34 AM - 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: 4DATE:
02/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Staff Bella NavaltaTIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit and was greeted by Staff Bella Navalta and explained the reason for the visit.
The purpose of the visit is to complete the required inspection.
LPA toured the facility along with Staff Bella Navalta today 02/15/2024 at 9:20 AM and the following was observed:
Facility contains 4 Client Bedrooms and 2 Client Bathrooms, dining room, living room, and TV room.
Annual Inspection includes the following Domains:
Infection Control, Physical Plant and Environment Safety, Operational Requirements, Staffing, Personnel Records- Training, Client Rights- Information, Client Records- Incident Reports, Food Service, Health Related Services, Incidental Medical Services, and Disaster Preparedness.
Interviews were conducted with the 1 staff on duty. 1 client was interviewed and the other client is non-verbal and was unable to respond to questioning. 2 client's were attending Day Program.
4 client files were reviewed and 7 staff files were reviewed. All staff were cleared and associated.
Medication was administered per physician's directions.
Signage for hand washing and proper sanitizing were posted. Staff have been trained in hand washing.
Licensee maintained an individual admission agreement for each client.
Fire Clearance has been maintained.
Facility had sufficient supply of 2 day perishable and 7 day non-perishables 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.
There is an adequate number of direct care staff to support each resident's physical, social, emotional safety and health care needs as identified in his/her current appraisal.
Facility has a sufficient supply of PPE.
Hot Water Temperature measured 139.9 F. and there were no warning signs posted on bathroom door.
Deficiencies cited on the 809 D. Exit interview conducted and copies provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2024
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 02/15/2024 11:34 AM - It Cannot Be Edited


Created By: Glenn Trueman On 02/15/2024 at 11:13 AM
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: 02/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 in with the temperature in clients bathroom measuring 139.9 F.which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2024
Plan of Correction
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Facility to submit a self declaration by POC due date to licensing that temperature will be between 105F. and 120F.
Also proof to be submitted of water temperature daily readings for 1 week.
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: 02/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/15/2024 11:34 AM - It Cannot Be Edited


Created By: Glenn Trueman On 02/15/2024 at 11:13 AM
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: 02/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (2) Taps delivering water at 125 degrees F (51.6 degrees C) or above shall be prominently identified by warning signs.

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 iwith there being no warning signs for client bathroom which had hot water temperature measure 139.9. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/15/2024
Plan of Correction
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Licensee shall submit proof by POC due date that warning sign is posted.
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: 02/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024


LIC809 (FAS) - (06/04)
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