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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601067
Report Date: 04/03/2023
Date Signed: 04/03/2023 02:36:35 PM

Document Has Been Signed on 04/03/2023 02:36 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:SYLVANWOOD RESIDENTIAL CARE HOMEFACILITY NUMBER:
198601067
ADMINISTRATOR:FABIAN, ALVIN S.FACILITY TYPE:
735
ADDRESS:16428 SYLVANWOOD AVENUETELEPHONE:
(562) 860-6041
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 4CENSUS: 4DATE:
04/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Sheila Fabian, Assistant AdministratorTIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with DSP Lerma Cacayurin and explained the purpose of the visit. Assistant Administrator Sheila Fabian arrived shortly after. There are four (4) ambulatory developmentally disabled clients in the home. The facility is licensed as a level 4D Adult Residential Facility (ARF) vendored by Harbor 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 screening station at the entrance of the facility. Each client room is designated as a COVID-19 isolation room if needed. An Infection Control Plan and COVID-19 Mitigation Plan was reviewed.


Physical Plant/Environment Safety:
  • The facility is a single story home located in a residential neighborhood that is licensed for four (4) non-ambulatory clients. It consists of 4 client bedrooms, 1 live-in staff room, living room, dining room, kitchen, 2 bathrooms, backyard patio area, and detached 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 are operational. The facility has one (1) fully charged fire extinguisher. Cleaning supplies and toxic substances are inaccessible to clients.
  • Water temperature readings measured between the required 105 - 120 degrees Fahrenheit.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 04/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2023
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SYLVANWOOD RESIDENTIAL CARE HOME
FACILITY NUMBER: 198601067
VISIT DATE: 04/03/2023
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Operational Requirements:
  • The Program Design was reviewed.
  • Fire clearance was approved by LA County Fire Department for three (3) ambulatory and one (1) non-ambulatory clients.
  • Care and supervision to meet the clients needs was observed. Special equipment and supplies to meet the persons with special needs were observed.
  • Current Surety bond and Certificate of Liability Insurance were reviewed.

Staffing:
  • A total of four (4) staff members provide care and supervision to the clients. Off which one (1) staff lives at the facility. An additional six (6) staff are scheduled as on-call.

Personnel Records/Staff Training:
  • Administrator certificate expires 11/9/2024.
  • For (4) 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 for postural supports and devices were reviewed in client files.

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, Restricted Health Care Plans, 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 physician orders for modified diets are in place.

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

DATE: 04/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2023
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SYLVANWOOD RESIDENTIAL CARE HOME
FACILITY NUMBER: 198601067
VISIT DATE: 04/03/2023
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Health Related Services:
  • Clients are assisted with self administration of prescription and non-prescription medications.
  • One (1) client is diabetic and self administers insulin injections. NOTE: Client (C1's) insulin medication is stored unlocked in the kitchen refrigerator. A deficiency was cited.
  • 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 an on file. Client (C1's) Restricted Health Care Plan was reviewed.
  • Staff training was on file.

Disaster Preparedness, and Emergency Intervention:
  • A posted Emergency Disaster Plan LIC 610D containing emergency evacuation information was observed. However, the most current LIC 610D required has not been completed. A technical advisory was issued.
  • An emergency drill was conducted on 3/2/2023. The facility shall conduct a drill at least quarterly for each shift.


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


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

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

DATE: 04/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/03/2023 02:36 PM - It Cannot Be Edited


Created By: Noemi Galarza On 04/03/2023 at 02:20 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: SYLVANWOOD RESIDENTIAL CARE HOME
FACILITY NUMBER: 198601067

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 that client (C1's) insulin medication is stored unlocked in the kitchen refrigerator, which poses an which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2023
Plan of Correction
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Licensee shall ensure that insulin medication is locked and stored inaccessible to clients. Licensee stated a medication locked box will be purchased and insulin will be stored locked in the refrigerator.
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: 04/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2023


LIC809 (FAS) - (06/04)
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