198600780-7-29-2024-28-AS-TRES-D7MVWC-20240729164742

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600780
Report Date: 07/29/2024
Date Signed: 07/29/2024 04:48:24 PM

Document Has Been Signed on 07/29/2024 04:48 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	GRAYSTONE HOME		FACILITY NUMBER:	198600780
ADMINISTRATOR/ DIRECTOR:	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:	07/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:32 PM
MET WITH:	Juanito Paguio Administrator		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

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Licensing Program Analyst (LPA) Tyler Reyes conducted the required annual inspection. LPA arrived unannounced and met with Juanito 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. LPA observed with Administrator Juanito two Glade Air Spray Cans in C1's closet on the floor in a bag.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. The hot water temperature was tested in both bathrooms and measured within the required range of 105-120 degrees. The last Fire/Emergency Drill was conducted on 7/1/2024. 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: Fernando Fierros
LICENSING EVALUATOR NAME: Tyler Reyes
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024

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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GRAYSTONE HOME	FACILITY NUMBER: 198600780
	VISIT DATE: 07/29/2024

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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 Juanito's certificate expires 1/13/26.
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.

Deficiencies were noted on todays visit per Title 22. Appeals rights discussed and a copy provided. Exit interview conducted with Administrator

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Tyler Reyes
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/29/2024 04:48 PM - It Cannot Be Edited

Created By: Tyler Reyes On 07/29/2024 at 04:28 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: GRAYSTONE HOME	FACILITY NUMBER: 198600780
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/29/2024

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as during a tour LPA observed with Administrator Juanito two Glade Air Spray Cans in C1's closet on the floor in a bag, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/30/2024
	Plan of Correction
1 2 3 4	Administrator to conduct a training that covers proper storage of disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. All staff must complete training and a copy of the training materials and participant list is to be emailed to LPA Reyes.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Fernando Fierros

LICENSING EVALUATOR NAME:

Tyler Reyes

LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024

LIC809 (FAS) - (06/04)

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