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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601122
Report Date: 05/07/2024
Date Signed: 05/07/2024 08:38:31 PM

Document Has Been Signed on 05/07/2024 08:38 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:INSPIRATION HOMES IIFACILITY NUMBER:
198601122
ADMINISTRATOR/
DIRECTOR:		MARSHA HAYWOODFACILITY TYPE:
735
ADDRESS:6745 NORTH GOLDEN WEST AVE.TELEPHONE:
(626) 445-7959
CITY:ARCADIASTATE: CAZIP CODE:
91007
CAPACITY: 4CENSUS: 4DATE:
05/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:46 AM
MET WITH:Direct Support Staff Lidia Casala TIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Kimberly Ramirez conducted an unannounced Annual Inspection visit on 05/07/2024. LPA Ramirez were met by Direct Support Staff Lidia Casala and explained the purpose of the visit. This facility is licensed as an Adult Residential Facility and is serviced by East Los Angeles Regional Center. The facility is licensed to serve four (4) developmentally disabled clients ages 18 and above; of which all must be ambulatory. During today’s visit, LPA Ramirez observed two (2) direct support staff (DSP) providing direct care and supervision to clients in care. LPA Ramirez requested and obtained copies of Personnel Report, and Client Roster.
LPA OBSERVATIONS: The facility is a single-story home that contains three (3) bedrooms, one (1) client bathroom, (1) staff bathroom, living room, kitchen, dining room, laundry room, backyard, and shaded patio area.

Front Yard: LPA Ramirez observed front yard to be free of hazards.

Kitchen: LPA Ramirez observed appliances to be clean and in working order. LPA Ramirez did not observe sufficient 2 days of perishables and 7-day supply on non-perishables. Per interview with staff, on 5/3/24, the facility refrigerator was not functioning properly and a temporary refrigerator was brought into the facility. LPA Ramirez observed nearby deep freezer with sufficient frozen meats and other foods. LPA Ramirez observed 1 dozen eggs, gallon of milk, cheese, and others lunch meats and various other veggies and fruits in the temp fridge. LPA Ramirez observed knives and sharps located kitchen cabinet, to be inaccessible to two (2) out of four (4) clients in care. LPA Ramirez kitchen cabinet drawer to be in disrepair. LPA Ramirez will issue Type B deficiency. Dining Room/Living room: Dining room was observed to contain one table with several chairs. The living room was observed to contain plenty of lighting and natural lighting. LPA Ramirez observed a fully charged fire extinguisher nearby. LPA Ramirez observed one (1) client sitting in this area during inspection. Linen Closet/Supply Closet: Observed to contain plenty linens, towels, and hygiene products.

SEE 809-C for continuation.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2024
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 05/07/2024 08:38 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 05/07/2024 at 11:42 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: INSPIRATION HOMES II
FACILITY NUMBER: 198601122

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2024

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, water temperature in client bathroom#1 measured at 133.0 degrees F, the licensee did not comply with the section cited above in 4 out of 4 clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2024
Plan of Correction
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*Staff adjusted controls during visit. This clears 24hr correction.* Licensee will create water log and record water temperatures for the next 3 business days and send log via fax to LPA Ramirez by 05/15/24.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/07/2024 08:38 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 05/07/2024 at 11:42 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: INSPIRATION HOMES II
FACILITY NUMBER: 198601122

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, kitchen cabinet drawer is in disrepair, the licensee did not comply with the section cited above in 4 out of 4 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2024
Plan of Correction
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Licensee will repair cabinet and send picture proof by 05/15/2024. Must be submitted via fax.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024


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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: INSPIRATION HOMES II
FACILITY NUMBER: 198601122
VISIT DATE: 05/07/2024
NARRATIVE
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Client Rooms 1 - 3: One (1) client bedroom is shared and the other two (2) are private. LPA Ramirez observed all client bedrooms to contain the required linens, furnishings, and lighting.

Bathroom 1-2: Bathroom#1 is only accessible to clients and visitors. Water temperature in this bathroom was measured at 133.0 degrees F. Bathroom#2 is only accessible to staff through laundry room entrance. LPA Ramirez will issue Type A deficiency based on observation for water temperature in client bathroom#1.

Backyard: No large bodies of water were observed.

Emergency Drills: Last documented disaster drill was conducted on 02/01/2024 and 11/22/2023.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide and smoke detectors in hallways. Smoke detectors were observed to be operable during visit. Fully charged fire extinguishers were observed throughout the facility.

Personnel Records: Personnel records are maintained at the facility. LPA Ramirez reviewed two (2) personnel records. First Aid Certificate, Fingerprint Clearance/ Exemptions, Personnel Record/Job Application, Health Screening, Employee Rights, TB Test, and Initial/Annual Training Verification. Administrator’s certificate for Marsha Haywood was observed with an expiration date of 04/05/2025.

Client Records: Client files are maintained at the facility. LPA Ramirez reviewed four (4) client records. No deficiency was observed. Admissions Agreement, Medical Assessment, Consent Forms, Appraisal and Needs and Services plan, I.D and Emergency Information, TB Test, Centrally Stored Medication Record, and Personal Rights Form.

Infection Control Plan: LPA Ramirez observed infection control plan.

Two (2) deficiencies and three (3) technical advisories were cited. Exit interview was conducted. A copy of this report, 809-D, LIC 9102 and appeals rights was provided

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024
LIC809 (FAS) - (06/04)
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