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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600692
Report Date: 04/28/2023
Date Signed: 05/10/2023 08:43:08 AM

Document Has Been Signed on 05/10/2023 08:43 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:GUIDING LIGHT HOME 2FACILITY NUMBER:
198600692
ADMINISTRATOR:PASCASIO, ZONEL E.FACILITY TYPE:
735
ADDRESS:4828 CUTLER AVENUETELEPHONE:
(626) 814-4783
CITY:BALDWIN PARKSTATE: CAZIP CODE:
91706
CAPACITY: 5CENSUS: 5DATE:
04/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Brenda Parna TIME COMPLETED:
04:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Wong conducted the required annual inspection. LPA arrived unannounced and met with DSP Maria Didasa who allowed the entry of the facility and assisted with the visit. Shortly after, the house manager Brenda Parna arrived and assisted with the visit. The purpose for the visit was explained. The facility is licensed for five (5) ambulatory, develop-mentally disabled adults.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and here are the domains that LPA inspected:

1, Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting the clients. Staff are cleaning and disinfecting once a day, for high touched surface area, they would disinfect three times day. Facility has sufficient PPE supplies and has an Infection Control Plan.
2. Physical Plant and Environmental: The facility is a single story house and located around the residential neighborhood area. The facility includes: dining area, living room, kitchen, four clients bedrooms, two bathrooms, office room and an attached garage. LPA inspected the carbon monoxide detectors and located next to the dining area and its working properly. LPA also inspected the smoke detectors and its located in each bedroom and common area and they are all working well. LPA tested the hot water in two bathrooms and they were tested between 113.5 and 114 degrees F which is within Title 22 regulation. All the sharp utensils are locked in the kitchen drawer. The cleaning supplies and chemicals are locked in the cabinet in the garage and its inaccessible to the clients. All clients rooms are clean and furnished and have required beddings.
3. Operational Requirements: The facility maintained a fire clearance approved by the fire department which five ambulatory client and currently all clients in the facility are ambulatory. The facility also has shaded area with table and chairs for client to utilize for outdoor activity. The last fire drill were conducted on 4/1/23

(See LIC 809C for continuation)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2023
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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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: GUIDING LIGHT HOME 2
FACILITY NUMBER: 198600692
VISIT DATE: 04/28/2023
NARRATIVE
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4. Staffing: The facility has sufficient staffing in the facility and the night supervision staff all have the planned emergency procedure training.
5. Personnel Record-Training: All the staff files are maintained in the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. The administrator's Zonel Pascasio certificate will be expired on 3/17/2024. The administrator also has an updated HIV and TB Training. All the direct care staff has the updated first aid training and the required in service training.
6. Clients Right-Information: The facility does not have any client required postural support. The facility does serve adults has internet service shall provide at least one access device.
7. Client Records-Incident Reports: All the client files are maintained in the facility. All the files have the required documents included: admission agreement, updated physician report , Individual Personal Plan (IPP) except functional capacity assessment (C1-C4)
8. Food Service: The facility has two days perishable and seven days non-perishable food supply. The refrigerator is maintained in the required temperature. All the food are stored probably.
9. Health Related Services: All client medication are centrally stored and locked in the file cabinet next to the dining area All the client's medication are reviewed and they are all seemed accurate and updated.
10. Incidental Medical Services: The facility does not have any client who has the restricted health condition or prohibited health condition.
11. Disaster Preparedness: The facility does not have an updated emergency disaster plan (LIC610D) posed in the facility but staff does have and annual emergency preparedness training. Facility only conducted fire drill quarterly but did not indicate the names of the staff participating in the drill. The facility did not conduct the disaster drill every 6 months. On the facility sketch, it also does not include the identification of an assembly points.
12. Emergency Intervention: All staff have required training including the ProAct and CPR training and they are all updated.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 1

Exit interview was conducted, Appeals Rights discussed and a copy of the report was given to the administrator Brenda Parna
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 05/10/2023 08:43 AM - It Cannot Be Edited


Created By: Christine Wong On 04/28/2023 at 03:36 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: GUIDING LIGHT HOME 2
FACILITY NUMBER: 198600692

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.2(b)(1)(F)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (F) The written functional capabilities assessment specified in Section 80069.2.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA observed four clients does not have the written functional capabilities assessment in the client file which posed a potential risk to the clients.
POC Due Date: 05/12/2023
Plan of Correction
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The administrator will send the four clients fucntional capabilities assessment to LPA by POC due date.
Type B
Section Cited
HSC
1565(a)(1)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (1) Evacuation procedures, including identification of an assembly point or points that shall be included in the facility sketch.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA did not observe the identification of an assembly point in the faciltiy sketch which posed a potiential risk to clients.
POC Due Date: 05/12/2023
Plan of Correction
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The adminsitrator will send the updated facility sketch to LPA By POC due date which include the identification of an assembly point
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:David Sicairos
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 05/10/2023 08:43 AM - It Cannot Be Edited


Created By: Christine Wong On 04/28/2023 at 03:36 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: GUIDING LIGHT HOME 2
FACILITY NUMBER: 198600692

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA observed the fire drill does not indicate any name of staff particioate in the drill which posed a potential risk to clients in care.
POC Due Date: 05/12/2023
Plan of Correction
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The administrator will send the updated fire drill to LPA by POC due date include the names of the staff that particiated in.
Type B
Section Cited
HSC
1565(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee, administrator, or regulated individual shall sign and date the documentation to indicate that the plan has been reviewed and updated as necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA observed the emergency and disaster plan was dated on 2020 which was not reviewed annuall and posed a potential risk to clients in care.
POC Due Date: 05/12/2023
Plan of Correction
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The adminsitrator will update the emergency and diaster plan and send the updated form LIC610D to LPA by POC due 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:David Sicairos
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 05/10/2023 08:43 AM - It Cannot Be Edited


Created By: Christine Wong On 04/28/2023 at 03:36 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: GUIDING LIGHT HOME 2
FACILITY NUMBER: 198600692

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80023(d)
Disaster & Mass Casualty Plan
(d) 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, staff reported that they did not conduct diaster drill in the facility which posed a potential risk to clients in care.
POC Due Date: 05/12/2023
Plan of Correction
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The administrator will send the updated disaster drill to LPA by POC due date which include the name of staff that participates in
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:David Sicairos
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5