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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601027
Report Date: 11/02/2021
Date Signed: 11/16/2021 03:49:33 PM

Document Has Been Signed on 11/16/2021 03:49 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:REDEEMER HOME IIFACILITY NUMBER:
198601027
ADMINISTRATOR:BERNAL, JOSEFINA R.FACILITY TYPE:
735
ADDRESS:2712 GREENLEAF DRIVETELEPHONE:
(626) 839-1761
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY: 6CENSUS: 5DATE:
11/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:46 AM
MET WITH:Josefina Bernal, AdministratorTIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with DSP staff Elizabeth Hing and explained the purpose of the visit. Administrator Josefina Bernal arrived shortly after and was explained the purpose of the visit. There are five (5) level 4B developmentally disabled clients ages 18-59 in the home. The facility is a single story home located in a residential neighborhood that is licensed for 6 clients; of which two (2) can be non-ambulatory. It consists of 3 client bedrooms, office, living room, dining room, family room, kitchen, 2 bathrooms, backyard patio area, and attached garage. The last fire drill was conducted on 4/5/2021. Administrator certificate expires 2/25/2023.

The following were observed/inspected:
  • The interior and exterior physical plant was inspected.
  • COVID-19 Infection Control signs were observed in the entrance, common areas, hallways, and bathrooms.
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • Each client's room is designated as a COVID-19 solation room if needed.
  • Five (5) centrally stored resident medication records were reviewed.
  • Staff (S1) was not observed wearing mask when the door was answered.
  • Client's wear masks in the home as tolerated except during meal times.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
  • A posted Emergency Disaster Plan was observed.
  • Sufficient supply of Personal Protective Equipment (PPEs) was observed.
  • Staff and resident files were not reviewed during today's visit.
  • Bedroom #1's window was missing a screen.
  • The left side iron gate door was observed to have a double sided door knob that requires a key from the interior of the facility. However it was not locked at the time of the visit. A technical violation was issued.
Deficiencies were cited. See LIC 809D.
Exit interview was conducted with staff Josefina Bernal. A copy of the report was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2021
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 11/16/2021 03:49 PM - It Cannot Be Edited


Created By: Noemi Galarza On 11/02/2021 at 11:48 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: REDEEMER HOME II
FACILITY NUMBER: 198601027

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1550(c)
Suspension and Revocation
(c) Conduct which is inimical to the health, morals, welfare, or safety of either the people of this state or an individual in, or receiving services from, the facility or certified family home.

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 that upon entry into the home LPA observed that staff (S1) was not wearing a surgical mask, and did not follow COVID-19 screening protocols. In addition, no visitor log was observed; only staff screening log which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2021
Plan of Correction
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Administrator shall re-train all staff on COVID-19 infection control screening protocols, and place a visitor log at the entry table. Submit proof of staff re-training and a picture of the visitor log placed at the main entrance screening area.
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 during physical plant inspection of the kitchen area at 11:15 the sharps/knives drawer and under kitchen sink where cleaning agents are stored were observed unlocked; which poses an immediate health, safety or personal rights risk to persons in care. Staff (S1) immediately locked both drawers.
***Cleared during the visit.
POC Due Date: 11/02/2021
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:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2021


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/16/2021 03:49 PM - It Cannot Be Edited


Created By: Noemi Galarza On 11/02/2021 at 11:48 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: REDEEMER HOME II
FACILITY NUMBER: 198601027

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on physical plant observation at 11:19 am the licensee did not comply with the section cited above in that bedroom #1's window did not have a window screen which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/09/2021
Plan of Correction
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Administrator shall install a window screen in bedroom #1 by POC due date.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2021


LIC809 (FAS) - (06/04)
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