Facility is licensed to serve six (6) developmentally disabled adults, ages 18-59. Two can be non-ambulatory. All clients residing at this facility receive case management services by San Gabriel/ Pomona Regional Center.

FACILITY TOUR AND OBSERVATIONS:

Personal Rights postings were observed in a common area. Residents had access to personal space, privacy, and adequate storage. No firearms/weapons were present.

Physical Plant

The facility is a one-story residential home consisting of four (3) client bedrooms, (1) staff bedroom, kitchen, dining room, living room, two (2) bathrooms, an attached garage with storage and laundry, and a backyard patio. All three bedrooms contained the required furniture, including a bed with a clean mattress, linens, dresser, chair, and adequate lighting. Extra clean linens and towels were stored in hallway cabinets, and all furniture was in good condition. Both bathrooms were equipped with working sinks, toilets, and showers, as well as the required grab bars and non-skid mats. Bathrooms had working fixtures, grab bars, and non-skid mats; hot water measured in bathroom (1) 114.6°F and bathroom (2) 109.4 °F within 105–120°F. While conducting a walk through of the kitchen LPA observed ants on kitchen counters, top or refrigerator and in cereal containers. Smoke/carbon monoxide detectors were functional, and a charged fire extinguisher was available mounted in dining room area. Exits were clear, and no bodies of water were present. Backyard provided shaded seating; garage contained laundry and locked storage for chemicals.

(Continued on 809C)

• Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

• Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

Refrigerators/freezers were maintained at proper temperatures (refrigerators maximum of 40 degrees F and freezer 0-degree F) with sufficient supply of 2-day perishable and 7 days non-perishable food. An additional refrigerator in garage with frozen food, fruits and proteins. Knives are locked in kitchen drawer and cleaning supplies are locked in kitchen cabinet under the sink inaccessible to clients.

Health-Related Services & Records:
Six (6) client files were reviewed and contained current required documents (Admissions Agreements, Pre-Placement Appraisals, Consents, Needs/Service Plans, Physician’s Reports with TB/ambulatory status, Rights acknowledgments, and IPPs). Medical/dental care was current. Five (5) medications were reviewed; medications are centrally stored in kitchen cabinet, locked, and labeled. MAR logs were current. P&I funds were reviewed.

Disaster Preparedness:
Last fire/earthquake drill was conducted on September 15, 2025, with logs available. LIC 610D Emergency Disaster Plan was posted in the dining room area. Emergency supplies (water, food, flashlights, batteries, first aid) were observed in the garage. Infection Control Plan was updated.

Personnel Records & Training:
Three (3) staff files were reviewed and included criminal record clearances, CPR/First Aid, DSP training, and TB screenings.

Insurance:
Liability insurance was in compliance with an expiration date of 1/12/26.

An exit interview was conducted with Roxanne Arcibal,Facility Coordinator. During the inspection, a deficiency was observed and cited on the attached LIC 809D/809C in accordance with Title 22, Division 6 regulations. The Administrator was advised of the nature of the deficiency, the regulatory basis, and the required Plan of Correction (POC). The Administrator agreed to submit proof of correction by the due date specified. A copy of this report, LIC 809D/809C, and appeal rights will be provided via email.