198601173-3-24-2023-28-AS-KRAZ-CQ8SED-20230324134834

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601173
Report Date: 03/24/2023
Date Signed: 03/24/2023 01:49:18 PM

Document Has Been Signed on 03/24/2023 01:49 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	WEDGEWOOD HOME		FACILITY NUMBER:	198601173
ADMINISTRATOR:	AFRICA C. JUNIO		FACILITY TYPE:	735
ADDRESS:	9227 WEDGEWOOD ST.		TELEPHONE:	(626) 703-4366
CITY:	TEMPLE CITY	STATE: CA	ZIP CODE:	91780
CAPACITY: 6		CENSUS: 3	DATE:	03/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	07:40 AM
MET WITH:	Administrator Africa Junio		TIME COMPLETED:	01:45 PM

NARRATIVE

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 03/24/2023 at 7:45 am. LPA was met by Administrator Africa Junio and explained the purpose of the visit. Facility is licensed to residents 18 to 59 years old. There are three (3) level 4A developmentally disabled clients residing at this facility. Residents at this facility are receiving services from East Los Angeles Regional Center. LPA requested and obtained a copy of Personnel Report (LIC 500), and Resident Roster (LIC 9020).

LPA OBSERVATIONS: Tour began at 8:02 am and was led Administrator Junio. The Facility is a single-story building located in a residential area with two (2) client shared bedrooms, one (1) staff bedroom, two (2) shared bathrooms, living room, kitchen, dining room, front yard, backyard and detached car garage.

· Front Yard: Was clean and well maintained. No hazards were observed.

· Kitchen: LPA observed kitchen to be clean and appliances appeared to be in working order. LPA observed sufficient 2 days of perishables and 7-day supply on non-perishables. Kitchen sink water temperature was measured at 116.3 degrees F.

· Dining Room/Living room: Dining room was observed to be clean and contained one table and 5 chairs. Living room was observed to clean and contain plenty of seating, and plenty of lighting.

Client Rooms 1 - 2: All contained the required furnishings, linens and were observed to be clean.

· Shared Bathroom# 1: Shared resident bathroom# 1 was observed to be clean and contained soap and paper towels. Signs promoting hand washing were observed. Water temperature in this bathroom was measured at 108.7 degrees F which is in the required 105 – 120 degrees F. Grab bars observed near toilet.

· Shared Bathroom# 2: Water temperature in client bathroom #1 was measured at 113.3 degrees F. Grab bars and non-slip mats were observed in shower. Signs promoting hand washing were observed.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

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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Document Has Been Signed on 03/24/2023 01:49 PM - It Cannot Be Edited

Created By: Kimberly Ramirez On 03/24/2023 at 12:01 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: WEDGEWOOD HOME	FACILITY NUMBER: 198601173
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80075(k)(7)

Title 22, Division 6 Chapter 1 Article 06. Continuing Requirements 80075 Health Related Services This requirement is not met as evidenced by: (k)The following requirements shall apply to medications which are centrally stored: (7)The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:
	Deficient Practice Statement
1 2 3 4	Based on record review), at 9:20 am, it was discovered that C2 was given prescribed medications as directed however, staff had not been logging in C2 Medication Administration Record (MAR) am/pm doses for the past 24 days, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to 1 out of 3 persons in care.
	POC Due Date: 03/31/2023
	Plan of Correction
1 2 3 4	Staff S1 immediatley logged doses on MAR while LPA was present. Administrator/ Licensee will remind staff and re-train staff to log medication doses after client is administered medication. Proof of staff re-training is required via email.

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:

Tony Vasallo

LICENSING EVALUATOR NAME:

Kimberly Ramirez

LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: WEDGEWOOD HOME	FACILITY NUMBER: 198601173
	VISIT DATE: 03/24/2023

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·Centrally Stored Medications: LPA observed medications cabinet located in hallway to be locked and inaccessible to residents. LPA reviewed 3 client Medication Administration Records (MAR). At 9:20 am while LPA was reviewing C2 MAR, it was discovered that C2 was given prescribed medications as directed however, staff had not been logging in C2 Medication Administration Record (MAR) am/pm doses for the past 24 days. Administrator Junio logged in the am/pm doses while LPA was present.

· Garage: LPA observed extra bedding supplies, cleaning products and hygiene products. Garage was locked and inaccessible to residents. Emergency water supply and emergency food supply were observed.

· Backyard: Clean and free from hazards. LPA observed plenty of seating and shade.

LPA observed carbon monoxide in hallways. Smoke detector is hard wired and tested during visit. Administrator certificate was observed for Africa Junio (6013915735) with an expiration date of 03/22/24. Last fire drill was conducted on 03/02/23. LPA reviewed 4 staff files and 3 client files.

Deficiency is being cited during visit. Exit interview was conducted with Administrator Junio and a copy of this report and appeals rights was provided via email due to printer malfunction.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023

LIC809 (FAS) - (06/04)

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