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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600620
Report Date: 05/17/2022
Date Signed: 05/17/2022 11:57:42 AM

Document Has Been Signed on 05/17/2022 11:57 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:ESCOBAR ADULT RESIDENTIALFACILITY NUMBER:
198600620
ADMINISTRATOR:ESCOBAR, SYLVIA A.FACILITY TYPE:
735
ADDRESS:5916 BARTLETT AVENUETELEPHONE:
(626) 286-6768
CITY:SAN GABRIELSTATE: CAZIP CODE:
91775
CAPACITY: 6CENSUS: 5DATE:
05/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:19 AM
MET WITH:Gladis Escobar, StaffTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with DSP staff Gladis Escobar and explained the purpose of the visit. There are five (5) level 3 developmentally disabled clients ages 59 and under. Facility is a two-story home licensed for 6 ambulatory only clients. It is located in a residential area consisting of four (4) client bedrooms, (2) staff rooms, 3 bathrooms, kitchen, dining room, living room, family room, covered patio area, and attached garage with laundry area. The last fire drill was completed on 12/14/2021.

The following were observed/inspected:
  • COVID-19 Infection Control Practices were observed upon entry and in common areas.
  • Infection control signs, and other signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • Room #2 is designated as COVID-19 isolation room if needed.
  • Hand sanitizer was observed in common areas.
  • Staff responsible for direct care and supervision were observed wearing a mask.
  • Clients were not observed wearing masks in the home due to cognitive impairment.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
  • A Emergency Disaster Plan was posted. Please update if needed.
  • Sufficient supply of Personal Protective Equipment (PPEs) was observed.
  • Centrally stored medication records were reviewed. Client (C1) did not have a Health Care Restriction Plan for Diabetes.

A deficiency was cited.
Exit interview was conducted with staff Gladis Escobar. A copy of the report and appeal rights were issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2022
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 05/17/2022 11:57 AM - It Cannot Be Edited


Created By: Noemi Galarza On 05/17/2022 at 11:40 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: ESCOBAR ADULT RESIDENTIAL
FACILITY NUMBER: 198600620

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80092(b)(5
Restricted Health Conditions . (b) Care for the following health conditions must be provided only as specified in Sections 80092.1 through 80092.11. (5) Insulin-dependent Diabetes as specified in Section 80092.8.

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 that client (C1) does not have a Restricted Health Care Plan in place and is being administered insulin injections by staff which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2022
Plan of Correction
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Administrator shall submit proof of a Restricted Health Care Plan approved by MD and Regional Center team. In addition, staff shall obtain insulin administration training by a health care professional.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022


LIC809 (FAS) - (06/04)
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