198600717-7-14-2023-28-AS-CWOG-CTQUGD-20230714153411

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600717
Report Date: 07/14/2023
Date Signed: 07/14/2023 05:05:30 PM

Document Has Been Signed on 07/14/2023 05:05 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:	FRANCISQUITO HOMES		FACILITY NUMBER:	198600717
ADMINISTRATOR:	TUASON, CYNTHIA		FACILITY TYPE:	735
ADDRESS:	15704 EAST FRANCISQUITO AVENUE		TELEPHONE:	(626) 918-6712
CITY:	LA PUENTE	STATE: CA	ZIP CODE:	91744
CAPACITY: 6		CENSUS: 5	DATE:	07/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Cynthia Tuason		TIME COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Wong conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met Administrator Cynthia Tuason and explained the reason of the visit and assisted with the visit. The facility is approved for serve Developmentally Disabled Adults 18-59 years old and ambulatory only. The facility is licensed as a level 4C vendored by San Gabriel Pomona Regional Center. The following twelve (12) tool domains were observed and reviewed: Infection Control, Physical Plant/Environmental Safety, Operational Requirements, Staffing, Personal Records-Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incidental Medical Services, Disaster Preparedness and Emergency Intervention. 1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility still encourages hand washing and self symptom check of staff and visitors. The facility has an Infection Control Plan and COVID-19 mitigation plan in place. 2. Physical Plant & Environmental Safety: The facility is a single story house and located in a residential neighborhood area. The facility includes: living room, dining area, kitchen, small staff office, four clients bedrooms and two bathrooms, staff break room, storage room and a detached garage. Bedroom#1 and #4 have two beds, two chairs, night stands, drawer, required beddings and furniture and sufficient lighting and closet space. Bedroom#2 and #3 have one bed, one chair, one night stand, drawers, required bedding and furniture and sufficient lighting and closet space. The two bathrooms are clean, sanitary and in a good working condition. The hot water temperature tested in two bathrooms are between 111.3 and 112.6 degrees F which are within the Title 22 regulations. The passageway, walkway and patio are free of obstruction. There's extra linen stored in the hallway closet and extra personal hygiene products are stored in the storage room. The facility has night light in the hallway. The facility also has telephone services in the premises. (See LIC809C for continuation)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

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: FRANCISQUITO HOMES	FACILITY NUMBER: 198600717
	VISIT DATE: 07/14/2023

NARRATIVE

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The sharp knives and utensils are stored and locked in the medication cabinet next to the refrigerator. All the cleaning supplies and chemicals are stored in the storage room which are inaccessible to clients. All the appliances include stove, oven, microwave, refrigerator, washer and dryer and working probably. LPA also inspected the smoke detectors and carbon monoxide detectors and they are all working well.

3. Operational Requirement: The facility is licensed for 6 ambulatory clients. Currently all five clients are ambulatory. The last fire/disaster drill was conducted on July 2, 2023. The facility has a backyard patio with table and chairs for client to utilize. Client are allowed to attend or participate community activities if they want to.

4. Staffing: There's sufficient staffing in the facility. Two staff in AM and PM shift and One staff in NOC shift. The night supervision staff also have the required training for the planned emergency procedure.

5. Personnel Record-Training: All the staff files are maintained and stored in the facility. All the staff are over 18 years old. and they are all associated and fingerprint cleared with the facility. The facility administrator is Cynthia Tuason and her administrator certificate is going to expire on 10/21/2024. She also has updated HIV and TB training in file. Staff also have all the required documents in their personnel files includes health screening and TB test, updated First Aid Certificate and required medication management training..etc.

6.Client's Rights -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 clients files are maintained in the facility and stored at the small staff office and they all have the required documents included face sheet, admission agreement, physician report, ambulatory status, current medication list...etc

8. Food Services: Facility has sufficient food supply is stored in the kitchen consisting of: 2-day perishables, 7-day non-perishables. The refrigerator is maintained in the required temperature. All the food are stored probably.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

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: FRANCISQUITO HOMES	FACILITY NUMBER: 198600717
	VISIT DATE: 07/14/2023

NARRATIVE

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9. Health Related Servicers: The medication is centrally stored and locked in the medication cabinet next to the refrigerator. LPA inspected all five (5) clients' medication and they are all accurate and updated. LPA also inspected the first aid kit and its stored and locked in the medication cabinet, and they all have the required supplies in the kit.

10. Incidental Medical Services: Currently the facility has no client with prohibited health condition or restricted health condition.

11. Disaster Preparedness: Emergency and Disaster Plan LIC 610D is in place. The last quarterly fire/emergency drill was completed on 7/2/2023 and the facility also has two alternative temporary shelter location.

12. Emergency Intervention: Its not applied to the facility.

No deficiencies were observed during the visit.

Exit Interview conducted. The copy of the report was provided to administrator Cynthia Tuason

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

LIC809 (FAS) - (06/04)

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