198600780-9-16-2023-28-AS-THEA-CVQQ5L-20230916115208

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600780
Report Date: 09/16/2023
Date Signed: 09/16/2023 11:52:12 AM

Document Has Been Signed on 09/16/2023 11:52 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:	GRAYSTONE HOME		FACILITY NUMBER:	198600780
ADMINISTRATOR:	MARILYN PAGUIO		FACILITY TYPE:	735
ADDRESS:	12233 GRAYSTONE AVENUE		TELEPHONE:	(562) 682-8666
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY: 4		CENSUS: 4	DATE:	09/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Marilyn Paguio - Administrator		TIME COMPLETED:	12:00 PM

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Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Marilyn Paguio (Administrator) and explained the purpose of today’s visit. The facility is licensed to serve 4 developmentally disabled adults ages 18 to 59 years old.

The facility is a single-story home located in a residential area. A tour of the facility includes: living room, dining area, kitchen, pantry, laundry room, den, 4 client bedrooms, 2 bathrooms, 1 staff room, attached garage, front yard, and backyard.

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 still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan.

Physical Plant & Environment Safety: There are 4 client bedrooms, 2 bathrooms, 1 staff room, living room, dining area, kitchen, pantry, laundry room, den, attached garage, front yard, and backyard. Bathrooms are clean and operational. 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 and stored in a storage closet. The hot water temperature was tested in both bathrooms and measured within the required range of 105-120 degrees. All storage areas for cleaning solutions, toxins, knives, and hazardous items are stored in a secured/locked area and inaccessible to clients. The last Fire/Emergency Drill was conducted on 9/1/2023. Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguisher was observed and is fully charged. (Continued on 809-C)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2023

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: GRAYSTONE HOME	FACILITY NUMBER: 198600780
	VISIT DATE: 09/16/2023

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Operational Requirements: The facility has an approved fire clearance and outdoor activity area that is shaded and furnished for outdoor use.
Staffing: There appears to be sufficient staffing at all times in the facility. Administrator Marilyn Paguio certificate expired 7/5/23, however, administrator was able to show proof of pending renewal with CCL receipt date of 5/9/23.
Personnel Records-Training: Staff has criminal record clearance and current first aid and CPR. Staff files are maintained at the facility and kept in the staff room.
Client Rights-Information: Clients are provided with telephone and internet at the facility.
Client Records-Incident Reports: Client files are kept in a secure location within the staff room and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan.
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 has the proper training on file. Medication is properly labeled and are centrally stored in a locked cabinet and are in their original containers. During the visit today, LPA reviewed 4 clients’ medication no issues were observed.
Incidental Medical & Dental: All medications for clients are kept locked and inaccessible to other clients.
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Emergency Intervention: Clients at this facility do not have restraints nor do they require the use de-escalation techniques.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit.

Exit interview held and a copy of the report was provided to Administrator Marilyn Paguio

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2023

LIC809 (FAS) - (06/04)

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