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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600620
Report Date: 05/26/2023
Date Signed: 05/26/2023 12:35:05 PM

Document Has Been Signed on 05/26/2023 12:35 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: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: 4DATE:
05/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:54 AM
MET WITH:Gladis Escobar, StaffTIME COMPLETED:
12:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with DSP Gladis Escobar and explained the purpose of the visit. Administrator Sylvia Escobar was explained the purpose telephonically. There are four (4) ambulatory developmentally disabled clients in the home. The facility is licensed as a level 3 Adult Residential Facility (ARF) vendored by Eastern Los Angeles Regional Center.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention.

Infection Control:

  • Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor screening station at the entrance of the facility. Each client room is designated as a COVID-19 isolation room if needed. An Infection Control Plan has not been submitted. The facility has a COVID-19 Mitigation Plan.


Physical Plant/Environment Safety:
  • The 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 interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors are operational. The facility has one (1) fully charged fire extinguisher. Cleaning supplies and toxic substances are inaccessible to clients.
  • Water temperature readings measured between the required 105 - 120 degrees Fahrenheit.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: ESCOBAR ADULT RESIDENTIAL
FACILITY NUMBER: 198600620
VISIT DATE: 05/26/2023
NARRATIVE
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Operational Requirements:
  • The Program Design was reviewed.
  • Fire clearance was approved by LA County Fire Department for six (6) ambulatory clients.
  • Care and supervision to meet the clients needs was observed.
  • The Surety Bond expired June 16, 2021. Citation was issued.

Staffing:
  • A total of four (4) staff members provide care and supervision to the clients. Two (2) caregivers reside in the home.

Personnel Records/Staff Training:
  • Administrator certificate expires 11/21/2023.
  • Four (4) staff files were reviewed for criminal background clearance and training.
  • Personnel records have health/TB screenings, CPI training, certifications, and 1st Aid/CPR training.

Client Rights/Information:
  • Physician orders and C1's restricted healthcare plan were reviewed in client files.

Client Records/Incident Reports:
  • Four (4) client files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, IPP reports, personal rights, medical consent, nutritional assessments, medication records, Restricted Health Care Plans.
  • Personel & Incidental monies were not reviewed or available. Citation was issued.

Food Service:
  • The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.

See next page.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023
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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: ESCOBAR ADULT RESIDENTIAL
FACILITY NUMBER: 198600620
VISIT DATE: 05/26/2023
NARRATIVE
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Health Related Services:
  • Clients are assisted with self administration of prescription and non-prescription medications.
  • Four (4) centrally stored resident medication records were reviewed. One (1) client's centrally stored medications were not kept in a safe and locked place. Client (C1) has physician orders for insulin injections. Insulin medication was stored unlocked in the refrigerator. Citation was issued.
  • Medications are given according to Physician directions.

Incident Medical and Dental:
  • All clients have a Needs and Services Plan an on file.
  • Staff training was on file.

Disaster Preparedness, and Emergency Intervention:
  • A posted Emergency Disaster Plan LIC 610D containing emergency evacuation information was observed. However, the most current LIC 610D required is missing pages. A technical advisory was issued.
  • An emergency drill was conducted on 6/30/2022. The facility shall conduct a drill at least every six months. Citation was issued.


Emergency Intervention:
  • No manual restraints or seclusion are used with clients in care.


See LIC 9099D pages for deficiencies cited.

Exit interview conducted with staff Gladys Escobar. A copy of the report, appeal rights, and technical advisory was issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 05/26/2023 12:35 PM - It Cannot Be Edited


Created By: Noemi Galarza On 05/26/2023 at 11:28 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: 05/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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's) insulin medications are stored unlocked in the refrigerator; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/27/2023
Plan of Correction
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Administrator agreed to purchase a lock box for C1's insulin medication that is stored in the refrigerator. POC is due tomorrow.
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: 05/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2023


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 05/26/2023 12:35 PM - It Cannot Be Edited


Created By: Noemi Galarza On 05/26/2023 at 11:28 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: 05/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that Administrator has not submitted an Infection Control Plan (ICP); which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2023
Plan of Correction
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Administrator agreed to submit a copy of the Infection Control Plan (ICP) by POC due date.
Type B
Section Cited
CCR
80025(b)
Bonding
All licensees, other than governmental entities, who are entrusted to care for and control clients' cash resources shall file or have on file with the licensing agency, a bond issued by a surety company to the State of California as principal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that the Surety Bond on file expired June 16, 2021; which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2023
Plan of Correction
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Administrator shall submit proof of active Surety Bond policy.
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: 05/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2023


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 05/26/2023 12:35 PM - It Cannot Be Edited


Created By: Noemi Galarza On 05/26/2023 at 11:28 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: 05/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80026(h)(1)
Safeguards for Cash Resources, Personal Property, and Valuables of Residents.
Each licensee shall maintain accurate records of accounts of cash resources … Records of clients' cash resources maintained as a drawing account, which shall include a current ledger accounting, with columns for income, disbursements and balance, for each client. Supporting receipts for purchases shall be filed in chronological order.
This requirement was not met evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that P & I records were not recent or available for review; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2023
Plan of Correction
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Administrator agreed to update P &I records and submit copies of all client P & I records by POC due date.
Type B
Section Cited
CCR
80023(d)
Disaster and Mass Casualty Plan.
Disaster drills shall be conducted at least every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that the last fire drill was conducted on 6/30/2022; which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2023
Plan of Correction
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Administrator agreed to submit a copy of the most recent Fire Drill,
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: 05/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2023


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