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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600626
Report Date: 10/14/2023
Date Signed: 10/14/2023 03:22:21 PM

Document Has Been Signed on 10/14/2023 03:22 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:NEW BEGINNINGS ATCHINSONFACILITY NUMBER:
198600626
ADMINISTRATOR:JANICE COLLINSFACILITY TYPE:
735
ADDRESS:403 ATCHISON STREETTELEPHONE:
(626) 398-0911
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 6CENSUS: 4DATE:
10/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:33 AM
MET WITH:Sigaia BugsbyTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 10/14/2023. LPA Ramirez was met by Direct Support Staff (DSP) Sanyiza Busby and explained the purpose of the visit. The facility is licensed serve four (4) developmentally disabled clients 18-59 years old. The facility is a 4I level home. LPA Ramirez requested and obtained copies of Personnel Report (LIC 500), and Client Roster (LIC 9020). All clients in the home receive services from Frank D. Lanterman Regional Center.

LPA OBSERVATIONS: Tour began at 09:25 am and was led by LPA Ramirez. The facility is a two story dwelling located in a residential area with four (4) client bedrooms, one (1) staff office, two (2) bathrooms, kitchen, dining room, living room, detached garage, front yard, and backyard.

Front Yard: LPA Ramirez observed front yard to be free of hazards.

Kitchen: LPA Ramirez observed appliances to be in working order. LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located in kitchen cabinet, to be inaccessible to four (4) out of four (4) clients in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants located in kitchen cabinet, to be inaccessible to four (4) out of four (4) clients in care. LPA Ramirez observed a fully charger fire extinguisher nearby. Kitchen sink temperature was measured at 126.3 degrees F. LPA Ramirez will issue Type A deficiency.

Dining Room/Living room: Dining room was observed to contain one table with plenty of seating. Living room was observed with plenty of lighting. LPA Ramirez observed a fully charged fire extinguisher nearby. LPA Ramirez observed signage promoting cough and handwashing etiquette in this area. LPA Ramirez observed nearby thermostat to read 69 degrees F.

See 809-C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2023
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 6
Document Has Been Signed on 10/14/2023 03:22 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 10/14/2023 at 12:19 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: NEW BEGINNINGS ATCHINSON
FACILITY NUMBER: 198600626

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2023

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, downstairs bathroom #1 sink water temperature was measured at 126.3 degrees F, the licensee did not comply with the section cited above in 4 out of 4 clients, staff, and visitors, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/15/2023
Plan of Correction
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Licensee will lower water heater immediately. Licensee will provide LPA Ramirez with water temperature readings starting 10/15/23 and record AM and PM readings. In addition, Licensee will submit plan to train staff on measuring water temperature and title 22 regulation-8088(e)(1). Training must be completed and proof of all staff receiving training by 10/31/23. Must be submitted via email.
Type A
Section Cited
CCR
80088(e)(1)(2)
(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). (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:
Hot water temp in kitchen sink read 126.3 degrees F.
Deficient Practice Statement
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Based on observation , the licensee did not comply with the section cited above in 4 out of 4 clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/15/2023
Plan of Correction
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Licensee will identify sink area with warning sign indicating " Hot water may go above 125 degrees F."
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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2023


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 10/14/2023 03:22 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 10/14/2023 at 12:19 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: NEW BEGINNINGS ATCHINSON
FACILITY NUMBER: 198600626

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2023

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, mirrored-glass closet doors in client bedroom#4 was cracked and door was not on railing, the licensee did not comply with the section cited above in 1 out of 4 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2023
Plan of Correction
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Licensee will repair and send photo proof via email.
Type B
Section Cited
CCR
85165(f)(7)
Emergency Intervention Staff Training
(f) The administrator who will approve the continued use of a manual restraint or seclusion shall complete additional training which shall include the following: (7) Current first aid certification and current certification in the use of cardiopulmonary resuscitation (CPR).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, two out of four staff did not have updated first aid and CPR certification, the licensee did not comply with the section cited above in 4 out of 4 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2023
Plan of Correction
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Licensee will have staff renew certification and provide LPA Ramirez with copy of Staff #1 and Staff #2 certification.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2023


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 10/14/2023 03:22 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 10/14/2023 at 12:19 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: NEW BEGINNINGS ATCHINSON
FACILITY NUMBER: 198600626

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80086(a)
80086 Alterations to Existing Building or New Facilities
(a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.

This requirement is not met as evidenced by:
Facility altered existing grounds and did not notify this department. Facility altered 2nd downstairs bathroom directly across client bedroom#2 and is now a closet.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 4 out of 4 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2023
Plan of Correction
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Licensee will submit contract from construction company regarding alterations and remodel. Licensee will notify this licensing agency prior construction and alterations.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2023


LIC809 (FAS) - (06/04)
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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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: NEW BEGINNINGS ATCHINSON
FACILITY NUMBER: 198600626
VISIT DATE: 10/14/2023
NARRATIVE
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Linen Closet/Supply Closet: Observed to contain plenty linens, towels, and hygiene products.

Client Rooms 1 - 4: LPA Ramirez observed three client bedrooms to contain the required linens, furnishings, and lighting. Client in bedroom#2, did not allow LPA Ramirez entry. Client bedroom# 4 mirrored-closet door was not fully secured on railing and right mirror of closet door was cracked from right top corner down towards middle of glass. LPA Ramirez will issue Type B deficiency and civil penalty. Facility was previously cited on 8/28/23 for same violation.

Bathroom 1-2: LPA Ramirez observed grab bars in all showers and non slip mats in all bathroom showers. LPA Ramirez observed signage promoting proper handwashing etiquette near sink. Bathrooms were observed to be clean during visit. Prior facility sketch shows facility had three (3) client bathrooms. During visit, LPA Ramirez observed recent remodeling and alterations made to facility. Per Admin Harvey, the facility altered one of the client bathrooms located downstairs, across from client bedroom#2. This licensing agency did not receive notification prior to alterations being made. LPA Ramirez will issue Type B deficiency. LPA Ramirez did not observe updated facility sketch. LPA Ramirez will issue Technical Violation.

Centrally Stored Medications: LPA Ramirez observed medications to be locked in staff office cabinet.

Backyard: No large bodies of water were observed and area was free of hazards.

Emergency Drills: Proof of last documented fire drill and earthquake drill was on 10/05/23 at 3:30 pm and 10/05/23 at 3:00 pm.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide and smoke detectors in hallways. Smoke detectors were observed to be operable during visit.

Staff Personnel Files: Staff files are maintained at the facility. LPA Ramirez reviewed four (4) staff files. LPA Ramirez observed current Administrators Certificate with an expiration date of 12/27/24 for Margret Harvey. Two (2) out of four (4) staff (S1 and S2) did not renew CPR/First Aid certification. LPA Ramirez will issue Type B deficiency.

Client Files: Four (4) client files were reviewed.

Infection Control Plan: LPA Ramirez reviewed current infection control plan.

Exit interview was conducted. Deficiencies and one (1) technical violations were observed and noted. A civil penalty assessment of $250 was assessed due to repeat violation. A copy of this report, LIC 809-D, LIC 9102, LIC 421FC, and appeals rights was provided.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2023
LIC809 (FAS) - (06/04)
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