198600951-5-8-2023-28-AS-EZAA-CRMUND-20230508154345

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600951
Report Date: 05/08/2023
Date Signed: 05/08/2023 03:44:10 PM

Document Has Been Signed on 05/08/2023 03:44 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:	HARLAN RESIDENCE		FACILITY NUMBER:	198600951
ADMINISTRATOR:	JARAMILLO, JESSICA M.		FACILITY TYPE:	735
ADDRESS:	4133 HARLAN AVENUE		TELEPHONE:	(626) 338-0526
CITY:	BALDWIN PARK	STATE: CA	ZIP CODE:	91706
CAPACITY: 4		CENSUS:	DATE:	05/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:33 PM
MET WITH:	Marcos Hernandez - Administrator		TIME COMPLETED:	04:00 PM

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Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to Administrator Marcos Hernandez and subsequently conducted a tour of the facility. There are three (3) ambulatory and one (1) developmentally disabled clients who reside in the home. The facility is an Adult Residential Facility (ARF) vendored by the San Gabriel/Pomona Regional Center.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention.

Infection Control:

· Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station at the entrance of the facility. Each individual client bedroom may be designated COVID-19 isolation room if needed. The facility does have an Infection Control Plan and the administrator emailed to LPA Zaragoza while at the facility.

Physical Plant/Environment Safety:

· The facility is a single-story home located in a residential neighborhood that is licensed for two (2) non-ambulatory and two (2) ambulatory clients. It consists of 3 client bedrooms, a living room, dining room which is also an activity room, a kitchen, 2 (two) bathrooms of which the non-private restroom R#1 measured at 109.2 degrees F and private restroom in the master shared bedroom R#2 Measured 112.6 degrees F, backyard area, and an attached garage.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023

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: HARLAN RESIDENCE	FACILITY NUMBER: 198600951
	VISIT DATE: 05/08/2023

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· The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors are operational. The facility has one (1) fully charged fire extinguisher that is kept in the kitchen of the house. Cleaning supplies and toxic substances are inaccessible to clients.
· Water temperature readings measured between the required 105 - 120 degrees Fahrenheit.
Operational Requirements:
· The Program Design was reviewed.

· Fire clearance was approved by LA County Fire Department for two (2) ambulatory clients and two (2) non-ambulatory clients.

· Care and supervision to meet the clients needs was observed.
Staffing:

· A total of eight (8) full-time staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

· Administrator requested the renewal of his administrator’s certificate on 3/23/23 and will be sending LPA a copy of his renewed certificate.

· Five (5) staff files were reviewed for criminal background clearance and training.
· Personnel records have health/TB screenings, CPI training, certifications, and 1st Aid/CPR training.
Client Rights/Information:

· Physician orders were reviewed in client files.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023

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: HARLAN RESIDENCE	FACILITY NUMBER: 198600951
	VISIT DATE: 05/08/2023

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Client Records/Incident Reports:

· Four (4) client files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, IPP reports, personal rights, medical consent, nutritional assessments, medication records, and P & I money were reviewed.

Food Service:

· The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.

· No restricted Health Care plan required for the clients in the facility.
Health Related Services:

· Clients are assisted with self-administration of prescription and non-prescription medications.

· Four (4) centrally stored resident medication records were reviewed. Centrally stored medications are kept in a safe and locked place not accessible to clients in care. Medications are given according to Physician directions.

Incident Medical and Dental:

· All clients have a Needs and Services Plan.

· Staff training was on file.

Disaster Preparedness, and Emergency Intervention:

· A posted Emergency Disaster Plan LIC 610D containing emergency evacuation information was observed.

· An emergency drill was conducted on 024/16/2023.

Emergency Intervention:

· No manual restraints or seclusion are used with clients in care.

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.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023

LIC809 (FAS) - (06/04)

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