<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600880
Report Date: 05/11/2023
Date Signed: 05/11/2023 12:14:01 PM

Document Has Been Signed on 05/11/2023 12:14 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:INDIVIDUAL OPTIMUM LIFESTYLE APPROACHFACILITY NUMBER:
198600880
ADMINISTRATOR:ALICIA WALTERSFACILITY TYPE:
735
ADDRESS:1811 N ALLEN AVETELEPHONE:
(626) 791-1495
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 4CENSUS: 3DATE:
05/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:48 AM
MET WITH:Carlos Garcia TIME COMPLETED:
12:30 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(s)(LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA Flores met with Carlors Garcia Direct Support Staff(DS)P) and explained the reason for the visit. Alicia Walters Administrator arrived 15 minutes later.
The facility is licensed to serve four (4) Developmentally Disabled Clients ages 18 - 59 years. The facility is approved for two (2) Non-Ambulatory Clients. The facility is located in a residential area. A tour of the single-story facility includes: Two (2) client bedrooms, two (2) bathrooms, living room, kitchen, dining area, and indoor/outdoor activity areas.
LPA Flores conducted a tour of the facility with Heidy Flores DSP and observed the following;
Facility's living room has sufficient sitting space, a fireplace was observed with an item blocking it. A video surveillance system was observed in the common areas. Kitchen was observed clean and in working condition. Food supplies were observed sufficient for at least (2) days of perishables and (7) days of non-perishables. Medication and sharps cabinet was observed next to the dishwasher and lock. Passage way to the backyard was observed with a lock cabinet for cleaning supplies, a sink accessible to the clients water temperature was measured at 132.4 degrees F. Bathroom #1(B1) was observed in working condition water temperature was tested and measured at 128.3 degrees F., which is not within the required 105-120 degrees F. Bedroom #1(BR1) and Bedroom #2(BR2) were observed to have the required furniture and bedding supplies. BR1 was observed to have a lamp sufficient for one client and the light fixture in the ceiling was not working. BR2 half bed rails were observed for client #2(C2) no physician's request was observed in client's file. Front porch and backyard have shaded sitting area available. Smoke/Carbon monoxide detectors were tested and not working in BR1 and BR2. Fire extinguisher was observed and last checked on 4/13/23. Medication and files were checked for 3 clients and 5 staff files were checked. Emergency disaster plan was reviewed, last fire drill was conducted on 4/11/23. Administrator certificate was observed for Alicia Walters #6022731735 exp: 10/2/22. Documents have been submitted for renewal.
Deficiencies were noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Melvin Alvarez Manager and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
Document Has Been Signed on 05/11/2023 12:14 PM - It Cannot Be Edited


Created By: Mary G Flores On 05/11/2023 at 11:38 AM
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: INDIVIDUAL OPTIMUM LIFESTYLE APPROACH
FACILITY NUMBER: 198600880

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 in bathroom #1 and sink in passway to the right of the kitchen water temperature was a tested between 128.3 and 132.4 degrees F. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2023
Plan of Correction
1
2
3
4
Licensee will ensure water temperature is maintain within the required 105-120 degrees F., at all times and certify via LIC 9098 by POC due date 5/12/23. A daily water temperature log will be kept for the next 7 days and submitted to the department by 5/17/23.
Type A
Section Cited
CCR
80072(a)(8)(B)
80072 Personal Rights

B) A written order from the client's physician indicating the need for the postural support shall be maintained in the client's record. The licensing agency shall be authorized to require additional documentation if needed to verify the order.


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in client #2 has half bed rails in bed and no physician's order on file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2023
Plan of Correction
1
2
3
4
Administrator will request a physician's report or remove half bed rails and submit a copy of request or a picture of removed bed rails to the department by POC due date 5/12/23.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2023


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 05/11/2023 12:14 PM - It Cannot Be Edited


Created By: Mary G Flores On 05/11/2023 at 11:38 AM
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: INDIVIDUAL OPTIMUM LIFESTYLE APPROACH
FACILITY NUMBER: 198600880

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

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 in smoke/carbon monoxide in bedroom #1 and bedroom #2 were tested and were not in working condition which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/18/2023
Plan of Correction
1
2
3
4
Administrator will replace smoke/carbon monoxide detectors and ensure they are in working condition at all times. Administrator will submit a picture of replaced smoke/carbon monoxide detectors to the department by POC due date 5/18/23.
Type B
Section Cited
CCR
85009(b)
Posting of a License
(b) In facilities with a licensed capacity of six or fewer the license shall be retained in the facility and be available for review upon request.

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 in facility's license was not posted at the time of the visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/18/2023
Plan of Correction
1
2
3
4
Administrator will post facility's license and submit a picture to the department by POC due date 5/18/23.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/11/2023 12:14 PM - It Cannot Be Edited


Created By: Mary G Flores On 05/11/2023 at 11:38 AM
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: INDIVIDUAL OPTIMUM LIFESTYLE APPROACH
FACILITY NUMBER: 198600880

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(d)
Fixtures, Furniture, Equipment, and Supplies
(d) The licensee shall provide lamps or lights as necessary in all rooms and other areas to ensure the comfort and safety of all persons in the facility.

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 in light fixture in the ceiling in bedroom #1 is not in working condition and lamp does not provide sufficient lighting which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/18/2023
Plan of Correction
1
2
3
4
Administrator will ensure that light fixtures are in working condition and submit a picture of repairs to the department by POC due date 5/18/23.
Type B
Section Cited
CCR
85064(k)
Administrator Qualifications and Duties
(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in administrator last HIV training was conducted on 1/12/20 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/18/2023
Plan of Correction
1
2
3
4
Administrator will conduct training on HIV and submit a copy to the deparment by POC due date 5/18/23.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5