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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600611
Report Date: 01/28/2025
Date Signed: 01/28/2025 11:33:00 AM

Document Has Been Signed on 01/28/2025 11:33 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/
DIRECTOR:
ABRAJANO, JOSEPHFACILITY TYPE:
735
ADDRESS:5953 E. GALLANT ST.TELEPHONE:
(562) 928-1927
CITY:BELL GARDENSSTATE: CAZIP CODE:
90201
CAPACITY: 12CENSUS: 4DATE:
01/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Staff Bella NavaltaTIME VISIT/
INSPECTION 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 01/28/2024 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 3 client's were attending Day Program.
4 client files were reviewed and 1 staff file 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. Water temperature measured 105 F.
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 not 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.
Hallway light leading to client rooms was not operating and it was dark in the hallway.
Smoke Detector audibly stated low on battery.
Deficiencies cited on the 809 D. Exit interview conducted.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE: DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2025
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 01/28/2025 11:33 AM - It Cannot Be Edited


Created By: Glenn Trueman On 01/28/2025 at 11:16 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: 01/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 with hallway light leading to client rooms not operating and it was dark in the hallway and Smoke Detector audibly stated low on battery. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2025
Plan of Correction
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Facility to submit proof of corrections by POC due date.
Type B
Section Cited
CCR
80065(a)
Personnel Requirements
(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) and (record review)], the licensee did not comply with the section cited above with there being 1 staff on duty for all shifts which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2025
Plan of Correction
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Facility to submit proof of corrections by POC date.
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: 01/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2025


LIC809 (FAS) - (06/04)
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