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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600706
Report Date: 03/12/2024
Date Signed: 03/12/2024 03:00:38 PM

Document Has Been Signed on 03/12/2024 03:00 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:
03/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Mellanie G Aikman - AdministratorTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Tena Herrera conducted the required unannounced annual inspection. LPA met with Ariel Morales (caregiver) and explained the reason for the visit, shortly after at 12:10pm Administrator Mellanie G Aikman arrived to assist with the visit. The facility is licensed to serve (5) Developmentally Disabled Adults, ages 18 through 59, (3) ambulatory and (2) non ambulatory only. Facility currently has 4 Ambulatory clients serviced by Harbor Regional Center.

The facility is a single-story home located in a residential area in Bellflower, Ca. A tour of the facility includes: living room, dining area, kitchen, staff office, 5 client bedrooms, 2 client bathrooms, 2 staff bedrooms (one with a private bath), 2 staff bathroom, detached garage (with laundry), front yard and back yard.

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


Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility.
Physical Plant & Environment Safety: LPA toured facility, clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested in the client bathrooms and was within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked cabinet in the garage and are inaccessible to clients. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged. Cleaning supplies were found to be in an unlocked cabinet under kitchen sink and again in an unlocked cabinet in the client bathroom. (citation will be detailed in the 809-D)
(Continued on 809-C)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2024
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
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: 03/12/2024
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Operational Requirements: Staff have proper training to meet the needs of the clients in care. Facility has an activity area furnished for outdoor use. Last fire/earthquake drill was conducted on 3/6/24.
Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the clients in the case of an emergency.
Personnel Records-Training: Staff files are maintained in a secure location. LPA reviewed 4 staff files during today’s visit, files reviewed contained the following: Criminal Background Clearance, First-Aid/CPR/AED/CPI and sufficient on-going training. Administrator Mellanie G Aikman maintains a valid certificate that expires on 6/23/2025. While reviewing staff files LPA observed administrators file to be missing their first-aid certificate, proof of CPR/AED and CPI were in file. (citation will be detailed in the 809-D)
Client Rights-Information: Facility provides telephone landline and internet for the clients. Client rights posters and reporting posters are displayed within the facility.
Client Records-Incident Reports: Client files are maintained in a secured locked cabinet and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. LPA reviewed 4 client files with no issues.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Service: Staff designated to administer medication have the proper annual training on file. Medication is properly labeled and are centrally stored in a locked cabinet and are in their original containers. LPA reviewed 4 client’s medications during todays visit with no issues.
Incidental Medical & Dental: All training is documented in the facility personnel files. Staff performance is reviewed annually, and documentation is maintained in the personnel files.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Facility maintains documentation of the required emergency drills.
Emergency Intervention: Clients at this facility do not need the use of restraints or de-escalation techniques, however, staff are trained and maintain a CPI certificate if needed.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during todays visit will be documented on the 809D.

Exit interview was held and a copy of the report was given to Administrator Mellanie Aikman.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/12/2024 03:00 PM - It Cannot Be Edited


Created By: Tena Herrera On 03/12/2024 at 02:37 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: 03/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 as during physical plant tour LPA observed cleaning solution cabinet to be unlocked as well as disinfectants containing bleach were found in an unlocked cabinet in the client bathroom, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2024
Plan of Correction
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**during visit administrator quickly locked kitchen cabinet and removed cleaning solutions from unlocked bathroom cabinet and placed in the locked cabinet with all other cleaning supplies**
Administrator/Licensee to provide a training to all staff in proper safe keeping of items that could pose a danger if readily available to clients that inclued Disinfectants and Cleaning Solutions, a copy of training material and training log with participants and date of training to be submitted to LPA via email by 3/27/24.
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:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/12/2024 03:00 PM - It Cannot Be Edited


Created By: Tena Herrera On 03/12/2024 at 02:37 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: 03/12/2024

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 observation, the licensee did not comply with the section cited above as 1 out of 4 staff files reviewed were missing their first aid certificate (administator file was observed to have CPR/AED/CPI but missing first aid) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2024
Plan of Correction
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Administrator to schedule a First-Aid course as soon as possible, training must be completed by or before POC due date and a copy of the certificate must be emailed to LPA 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:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024


LIC809 (FAS) - (06/04)
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