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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600880
Report Date: 04/25/2024
Date Signed: 04/25/2024 01:03:18 PM

Document Has Been Signed on 04/25/2024 01:03 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/
DIRECTOR:		ALICIA WALTERSFACILITY TYPE:
735
ADDRESS:1811 N ALLEN AVETELEPHONE:
(626) 791-1495
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 4CENSUS: 4DATE:
04/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:39 AM
MET WITH:Carlos Garcia - StaffTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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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(DSP) 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 of which two (2) may be Non-Ambulatory. This is a level 4 home. The facility is located in a residential area, and consist of a single-story home with, (2) client bedrooms, (2) bathrooms, a living room, a kitchen, a dining area, and indoor/outdoor activity areas.

LPA conducted a tour of the facility with Carlos Garcia and Heidy Flores and observed the following:
Facility is currently going under construction to add two bedrooms and one bathroom to the left of the house to provide each client with their own room. Common areas (living room/dining room) were observed clean, with some furniture, and sufficient lighting. Kitchen was observed sufficient food for clients was observed for at least 2 days of perishables and 7 days of non-perishables. A detergent gallon was observed under the kitchen sink, medication cabinet and cleaning supplies cabinet were observed unlock, and accessible to the clients. Hallway between clients' bedrooms was observed with a hole in the wall the size of a quarter and two electrical cables the length of a ruler sticking out. Vent above the hallway was observed without proper coverage. Two clients' bedrooms were observed with sufficient lighting, furniture, and bedding supplies. Bedroom #1(BR1) had two client beds; Client #1(C1) bed has a 1/4 bed rail and Client #2(C2) has a full bed rail. No bed rail request were in file for C1 or C2. Client's bathroom was observed clean and in working condition. Water temperature was tested at 116.9 degrees F. which is within the required 105-120 degrees F. Fire extinguisher was observed last checked on 4/18/24. Smoke/Carbon Monoxide detectors were observed, tested, and in working condition. Front yard was observed with building material, backyard was observed with debris and furniture piled. Laundry is located in the garage. (CONTINUED ON LIC 809C)
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2024
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 4
Document Has Been Signed on 04/25/2024 01:03 PM - It Cannot Be Edited


Created By: Mary G Flores On 04/25/2024 at 11:59 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: 04/25/2024

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
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Based on observation, the licensee did not comply with the section cited above in detergent was observed under the sink, and cleaning supplies cabinet were observed unlock which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2024
Plan of Correction
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Administrator will provide training to staff regarding maintaining disinfectants, cleaning solutions, poisons inaccessible to the clients in care and will submit a copy of login sheet, agenda with title of training and duration of training by POC due date 4/26/24.
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in medication cabinet was observed unlock during the visit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2024
Plan of Correction
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Administrator will provide training to staff regarding maintaining medication inaccessible to the clients in care and will submit a copy of login sheet, agenda with title of training and duration of training by POC due date 4/26/24.
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: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/25/2024 01:03 PM - It Cannot Be Edited


Created By: Mary G Flores On 04/25/2024 at 11:59 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: 04/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in facility is currently under construction, wires were exposed in hallway, materials were observed in front yard, backyard was observed with contruction materials, furniture, umbrella post,vents are uncover, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/02/2024
Plan of Correction
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Administrator will ensure the construction continues safely by ensuring all vents are covered, materials are storage safely, and there are no dangers to the clients such as exposed wires will send pictures of the corrections to the department by POC due date 5/2/24. During the visit items began to be covered.
Type B
Section Cited
CCR
80072(a)(8)(B)
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
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Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 4 clients have bed rails in beds and there is no physician request on file C1 has a 1/4 rail and C2 has a full bed rail which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/02/2024
Plan of Correction
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Administrator will obtain physician's orders for both bed rails, in addition fro C2 administrator will submit an exception letter to the department for postural support, with the physician's order and Regional Center/family support letter by POC due date 5/2/24.
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: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024


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: INDIVIDUAL OPTIMUM LIFESTYLE APPROACH
FACILITY NUMBER: 198600880
VISIT DATE: 04/25/2024
NARRATIVE
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LPA reviewed files, medication for 4 clients, P&I money for 2 clients, and 5 staff flies. LPA conducted interviews with 2 staff and 2 clients. Administrator certificate was observed for Alicia Walters #6022731735 exp. date: 10/2/24.

Emergency Disaster Plan and Infection Control Plan were reviewed. Administrator will fax a copy of infection control to the department. In addition Administrator will submit a copy of approved city building permits, plan to ensure the safety of the clients and provide all care, information regarding utilities, clarification of construction starting date and date of completion, notification to the Regional Center and contact information.

Deficiencies are noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with Juan Mendoza 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: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC809 (FAS) - (06/04)
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