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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600706
Report Date: 04/24/2023
Date Signed: 04/24/2023 06:19:44 PM

Document Has Been Signed on 04/24/2023 06:19 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:CATHERINE'S HOMES, INC. (FLOWER ST)FACILITY NUMBER:
198600706
ADMINISTRATOR:MICHAEL SAN DIEGOFACILITY TYPE:
735
ADDRESS:9130 FLOWER STREETTELEPHONE:
(562) 263-9866
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 5CENSUS: 4DATE:
04/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Administrator, Mellanie AikmanTIME COMPLETED:
06:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was screened and met by Martin Carating Direct Service Professional (DSP) and explained the purpose of the visit. Administrator Mellanie AIkman arrived at 3:30pm and assisted LPA with the inspection. At 4:00pm, Michael San Diego, Assistant Administrator arrived and assisted LPA with the visit also. The facility is licensed to care for (5) Developmentally Disabled Adults, ages 18 through 59, (3) ambulatory and (2) non ambulatory only. All clients residing at this facility receive case management services provided by Harbor Regional Center.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a hand washing station by the entrance door and a visitor sign-in station located near the front door. The staff are wearing masks throughout their shift and disposable gloves are used to clean and disinfect the high touched surfaces in the common areas. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Facility has COVID-19 signage posted throughout the facility. Bathrooms have hand washing signs, soap and paper towels. Staff are adhering to infection control requirements.

Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. A fire clearance for five (5) ambulatory clients is in place. Surety Bond (Summa Insurance Services) is in effect and in force with bond amount of $1000. The insurance will expire on 01/20/2026. Last Fire Drill was conducted on 03/04/2023.

Physical Plant/Environment Safety: The facility is a single storey home located in a residential neighborhood, contains four (4) client bedrooms, two (2) staff bedrooms, four (4) full bathrooms, a family room, a living room, kitchen, dining area, office area, backyard, and a detached garage. Currently, there are four (4) clients living in the facility. Facility is Level 4I. The interior and exterior physical plant was inspected. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, chair and sufficient closet space. (3) Client bedrooms do not have a night stand. Bathrooms have non-skid materials and contained hygiene supplies including liquid soap, paper towels, and toilet paper. Exit doors are free of any obstruction and there are no pools or large bodies of water. Backyard was inspected and has a shaded area and sitting area. Detached garage was inspected and LPA observed that the garage is being used as a staff bedroom. There is a single twin bed in the corner of the garage and (2) staff who were sitting on the bed confirmed that they use the garage as bedroom. Kitchen knives, sharps objects, cleaning supplies and toxic substances are locked and inaccessible to clients. There are two (2) fire extinguishers observed to be fully charged and both were last serviced on June 6, 2022. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Hot water supply measured 11.9 deg F in the kitchen, 112.4 in bathroom #1, and 113.1 in bathroom #2.

*****REPORT CONTINUED ON LIC809-C*****

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2023
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: CATHERINE'S HOMES, INC. (FLOWER ST)
FACILITY NUMBER: 198600706
VISIT DATE: 04/24/2023
NARRATIVE
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Staffing: A total of six (6) staff members including the Administrator provide care and supervision to the clients. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility.

Personnel Records/Staff Training: Reviewed files for three (3) staff. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Administrator certificate is valid and expiring on 6/23/2023. Administrator has a valid HIV/AIDS training proof at the time of visit.

Client Rights-Information: Client personal rights are posted. Per Administrator, facility provides internet services to all clients and have access to the facility phone. Administrator also stated (1) out of (4) clients has his own personal cell phone and (1) out of (4) clients has his own tablet. LPA conducted client interviews during the visit as all (4) clients were out at the time.



Client Records-Incident Reports: LPA reviewed Client files for C1 through C4. Client files are maintained at the facility. Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Individual Program Plan (IPP), Behavioral Reports, Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights observed.

Food Service: There are sufficient food supplies of 2-day perishable and 7-day non-perishable items. The food is properly stored in the refrigerator (clean and well maintained). There are no clients with special diets residing at this facility. Pesticides and cleaning supplies are kept away from the food preparation areas (locked in the upper cabinet above the laundry machines). Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services The medications are centrally stored and in their original containers. Medications were reviewed for C1-C4 to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubbled packed.

Incidental Medical Services: Per the Administrator, there are no clients at this home with incidental medical services nor have a restricted health condition.

Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan. LPA provided a copy of the Care Tool standards covering Health and Safety Code 1565 and California Code of Regulation 80023 to the Administrator.

Emergency Intervention: Not-Applicable.

Deficiencies cited on LIC 809D. Exit interview, appeals rights and a copy of this report was provided to the Administrator, Mellanie AIkman.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/24/2023 06:19 PM - It Cannot Be Edited


Created By: Bennette Pena On 04/24/2023 at 05:32 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: CATHERINE'S HOMES, INC. (FLOWER ST)
FACILITY NUMBER: 198600706

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(2)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (2) Bedroom furniture including, in addition to (c)(1) above, for each client, a chair, a night stand, and a lamp or lights necessary for reading.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the Administrator did not comply with the section cited above in that 3 clients' bedrooms do no thave night stand] which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 05/01/2023
Plan of Correction
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Administrator will purchase side/night stand and will submit photos and receipts of the said items to LPA/CCLD by POC due date.
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:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/24/2023 06:19 PM - It Cannot Be Edited


Created By: Bennette Pena On 04/24/2023 at 05:32 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: CATHERINE'S HOMES, INC. (FLOWER ST)
FACILITY NUMBER: 198600706

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2023

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:
Deficient Practice Statement
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Based on observation, interview, record review, the Administrator did not comply with the section cited above in that the detached garage is being used as a staff bedroom. LPA observed a twin bed in the corner of the garage. Administrator did not notify CCLD or Fire or Building Inspector of the said alteration to the garage which poses an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 05/01/2023
Plan of Correction
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Administrator will ensure that staff working in the facility do not use the detached garage as bedroom. Administrator will submit photos that the twin bed has been cleared and removed. An in-service training on use of facility rooms will be conducted and a copy of the training signed by staff will be submitted to CCLD by POC due date.

Type B
Section Cited
CCR
85087(a)(3)(A)
85087 Buildings and Grounds
(a) In addition to Section 80087, bedrooms must meet, at a minimum, the following requirements:
(3) No room commonly used for other purposes shall be used as a bedroom for any person.
(A) Such rooms shall include but not be limited to halls, stairways, unfinished attics or basements, garages, storage areas, and sheds, or similar detached buildings.



This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the Administrator did not comply with the section cited above in that the detached garage is being used as a staff bedroom. LPA observed a twin bed in the corner in the garage and staff confirmed that he is using the garage as a bedroom which poses a potential health, safety or personal rights risk to clients in care.
POC Due Date: 05/01/2023
Plan of Correction
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Administrator will ensure that staff working in the facility do not use the detached garage as bedroom. Administrator will submit photos that the twin bed has been cleared and removed. An in-service training on use of facility rooms will be conducted and a copy of the training signed by staff will be submitted to CCLD 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:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2023


LIC809 (FAS) - (06/04)
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