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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600620
Report Date: 05/16/2024
Date Signed: 05/16/2024 12:43:03 PM

Document Has Been Signed on 05/16/2024 12:43 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/
DIRECTOR:		ESCOBAR, SYLVIA A.FACILITY TYPE:
735
ADDRESS:5916 BARTLETT AVENUETELEPHONE:
(626) 286-6768
CITY:SAN GABRIELSTATE: CAZIP CODE:
91775
CAPACITY: 6CENSUS: 4DATE:
05/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:13 AM
MET WITH:Gladis Escobar TIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Noemi Galarza made an unannounced annual inspection visit. The purpose of the visit was explained to caregiver Gladis Escobar. The facility is an Adult Residential Facility (ARF) that serves developmentally disabled residents ages 59 and under. The facility is a two-story home 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 following 12 (CARE) tool domains were utilized during the inspection.

Infection Control: The facility staff are using appropriate hand hygiene cleaning and disinfecting the home. An Infection Control Plan was reviewed.

Physical Plant/Environment Safety: 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 were tested and are operation. The facility has one (1) fully charged fire extinguisher. Hot water temperature readings measured between the required 105 - 120 degrees Fahrenheit. Storage areas for cleaning solutions/toxins, knives, and hazardous items were inaccessible to clients.

Operational Requirements: The Program Design was reviewed. Fire clearance is approved for six (6) ambulatory only residents. Care and supervision to meet the clients needs was observed. No special equipment and supplies are used by clients. Facility manages residents P & I monies. The Surety Bond expires 6/16/2025.



Staffing: A total of four (4) staff members provide care and supervision to the clients.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2024
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: 05/16/2024
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Personnel Records/Staff Training: Five (5) staff files were reviewed and contained criminal background clearance, in-service training, and health screening. Administrator certificate expired 11/2/2023; proof of certification completion was provided. Administrator stated that recertification documents were submitted to CCLD in September 2023. Recertification is pending approval.

Staff (S3 & S5) had expired CPR/First aid training.

Resident Rights/Information: Resident Personal Rights poster is posted on the facility refrigerator. Internet access is available for clients. Physician's orders are on file.

Resident Records/Incident Reports: Four (4) resident files were reviewed containing admission agreements, Physician's Reports, IPPs, medical/functional assessments, Behavior Reports, TB clearance, personal rights, medical consent, medication records, and P & I records.

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. The facility has 2 refrigerators.

Health Related Services: Residents are assisted with self administration of prescription and non-prescription medications. Four (4) centrally stored resident medication records were reviewed. Centrally stored medications are kept in a safe and locked place not accessible to clients in care. Medications are given according to Physician directions. 30-Day supply of medications were observed.

Incident Medical and Dental: All residents have a Needs and Services Plan and updated medical assessments.

Disaster Preparedness, and Emergency Intervention: A current LIC 610D updated form "Emergency Disaster Plan/Disaster and Mass Casualty Plan LIC 610D is posted.

The last Fire/Emergency Drill was conducted on 12/23/2023.

Emergency Intervention: No manual restraints, seclusion, or de-escalation techniques are used.

Per Title 22, California Code of Regulations, a deficiency was cited.


Exit interview with caregiver staff Gladis Escobar was conducted. A copy of the report/appeal rights were provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/16/2024 12:43 PM - It Cannot Be Edited


Created By: Noemi Galarza On 05/16/2024 at 12:11 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: ESCOBAR ADULT RESIDENTIAL
FACILITY NUMBER: 198600620

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

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 staff (S3 & S5) do not have current 1st Aid/CPR cards on file; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2024
Plan of Correction
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Administrator shall ensure all staff maintain current certification 1st Aid/CPR training.
Submit proof that CPR/1st Aid training was completed.
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: 05/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024


LIC809 (FAS) - (06/04)
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