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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600951
Report Date: 03/11/2024
Date Signed: 03/11/2024 12:35:57 PM

Document Has Been Signed on 03/11/2024 12:35 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:HARLAN RESIDENCEFACILITY NUMBER:
198600951
ADMINISTRATOR:JARAMILLO, JESSICA M.FACILITY TYPE:
735
ADDRESS:4133 HARLAN AVENUETELEPHONE:
(626) 338-0526
CITY:BALDWIN PARKSTATE: CAZIP CODE:
91706
CAPACITY: 4CENSUS: 3DATE:
03/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Marcos HernandezTIME COMPLETED:
12:45 PM
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Licensing Program Analysts (LPA) Nune Margaryan conducted an unannounced annual visit using the Care Tool. LPA met with Administrator Marcos Hernandez who assisted with the visit. LPA explained the reason for the visit.

The physical plant was inspected along with COVID-19 procedures, medications, food supply, and resident and staff records. The facility is licensed to serve developmentally disable clients between the ages 18 to 59 and vendorized by San Gabriel/Pomona Regional Center. There are currently 3 clients residing at the home and receive services from San Gabriel / Pomona regional Center. All 3 clients were at the Day program at the time of visit.


LPA toured the home and inspected three (3) client bedrooms, two (2) bathrooms, kitchen, dining room, the den, living room, and detached garage. The front and backyard are well maintained and there are no pools or large bodies of water. Passageways and exits are free of obstruction. There is a shaded seating area for the clients located in the backyard. Laundry was observed in the hallway. Also facility has a second pair of washer and dryer in the garage. LPA observed laundry detergent locked in the cabinet and in the garage and not accessible to clients. There is only one entrance being utilized at the facility. There is a fireplace located in the living room area which is covered by a screen.
Client bedrooms were checked. Each bedroom has a smoke detector, bed, linen, dresser, light, and sufficient closet space. The client bathrooms were toured. Bathrooms have the required hygiene items, grab bars and non-skid mat. The hot water temperature was tested and was measured 122.5 F- 123.4F . The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and working properly. Sharps are locked in a kitchen cabinet inaccessible to clients.

Continue 809C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2024
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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Document Has Been Signed on 03/11/2024 12:35 PM - It Cannot Be Edited


Created By: Nune Margaryan On 03/11/2024 at 11:51 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: HARLAN RESIDENCE
FACILITY NUMBER: 198600951

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2024

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
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Based on observation the licensee did not comply with the section cited above. Water temperature was tested in both bathrooms and reading was 122.5 F- 123.4F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/11/2024
Plan of Correction
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Water temperature was adjusted at the time of visit. No further action required.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Wei Siew Ho
LICENSING EVALUATOR NAME:Nune Margaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2024


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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HARLAN RESIDENCE
FACILITY NUMBER: 198600951
VISIT DATE: 03/11/2024
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LPA observed the centrally stored medication area to be locked and inaccessible to clients. The first aid kit was observed and found to be in compliance with the Title 22 Regulations. The carbon monoxide detector was observed in the living room and working properly. Fire extinguisher was fully charged and operational. LPA reviewed resident files to confirm emergency contacts have been updated. LPA confirmed staff working have fingerprint clearances. LPA reviewed clients medications. Medications are documented properly and given as prescribed.


Deficiency is being cited. See LIC 809D.
Exit interview was conducted with Marcos Hernandez. A copy of the report/appeal rights was issued.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024
LIC809 (FAS) - (06/04)
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