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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601027
Report Date: 09/28/2023
Date Signed: 09/28/2023 03:43:17 PM

Document Has Been Signed on 09/28/2023 03:43 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: 4DATE:
09/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:52 AM
MET WITH:Josefina Bernal, AdministratorTIME COMPLETED:
03:45 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 (LPA) Galarza 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 Josefina Bernal. There are four (4) ambulatory developmentally disabled adults ages 18-59. The facility is licensed as a level 4B home vendored by San Gabriel/Pomona Regional Center. Twelve (12) Adult CARE tool domains were observed and reviewed.

Infection Control:

  • Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility encourages hand washing and continues to screen visitors. An Infection Control Plan has been submitted to CCL.


Physical Plant/Environment Safety:
  • The facility is a single story home located in a residential neighborhood. It consists of 3 client bedrooms, 1 office room, 2 bathrooms, dining room/kitchen, living room, outdoor patio, and an attached garage.

  • 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 were tested and are operational. The facility has one (1) fully charged fire extinguisher.

  • Water temperature readings measured between the required 105 - 120 degrees Fahrenheit.


See next page
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2023
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 4
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: REDEEMER HOME II
FACILITY NUMBER: 198601027
VISIT DATE: 09/28/2023
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
26
27
28
29
30
31
32
Operational Requirements:
  • Fire clearance is approved for six (6) residents only, of which two (2) can be non-ambulatory.
  • Care and supervision to meet the clients needs was observed. Special equipment and supplies are not used by clients.
  • Surety bond ($2,000) expires Aug. 30, 2024.

Staffing:
  • A total of 10 staff members provide care and supervision to the clients.

Personnel Records/Staff Training:
  • Administrator certificate expired 2/25/2023. Per Licensee, the Certification unit received the recertification training proof, but as of today the certificate has not been processed.
  • provided.
  • Five (5) staff files were reviewed. Personnel record, health screening/TB clearance, training, zero-tolerance policy, and 1st Aid/CPR was on file. Criminal Record Clearance was checked. Staff (S1 & S2) are not associated to the facility. Citation was issued.

Client Rights/Information:
  • Physician orders, and personal rights were reviewed in client files.

Client Records/Incident Reports:
  • Four (4) resident 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, and medication administration records. Personal & Incidental (P & I) monies/records 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.
  • There are no physician orders for modified diets.

See next page.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: REDEEMER HOME II
FACILITY NUMBER: 198601027
VISIT DATE: 09/28/2023
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
26
27
28
29
30
31
32
Health Related Services:
  • Residents are assisted with self administration of prescription and non-prescription medications.
  • Centrally stored resident medication records were reviewed. They are kept in a safe and locked place not accessible to clients in care. Medications are given according to Physician directions. 30-Day supply of medications were observed.

Incident Medical and Dental:
  • All residents have a Needs and Services Plan, Physician Reports, and COVID-19 vaccination cards on file.

Disaster Preparedness, and Emergency Intervention:
  • A current Emergency Disaster Plan LIC 610D containing emergency evacuation information is in place. was not provided. The plan shall be reviewed annually, updated as necessary, and maintained on file at the facility.
  • First Aid Kit and Manual were observed.
  • The last emergency drill was conducted on 4/18/2023.


Emergency Intervention:
  • No manual restraints or seclusion are used with clients in care.

Per Title 22, California Code of Regulations, deficiency was cited.


Exit interview conducted with Administrator Josefinal Bernal. A copy of the report and appeal rights were issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 09/28/2023 03:43 PM - It Cannot Be Edited


Created By: Noemi Galarza On 09/28/2023 at 03:13 PM
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: 09/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or

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 that staff (S1 & S2) are cleared but not associated, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
1
2
3
4
Administrator shall submit LIC 9182 to CCL by tomorrow for (S1 & S2), and create a Guardian account. Submit proof by tomorrow.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 09/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2023


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