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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601300
Report Date: 11/17/2022
Date Signed: 11/17/2022 01:44:15 PM

Document Has Been Signed on 11/17/2022 01:44 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 IIIFACILITY NUMBER:
198601300
ADMINISTRATOR:JOSEFINA R. BERNALFACILITY TYPE:
735
ADDRESS:1916 VALERIE CTTELEPHONE:
(626) 893-4883
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY: 6CENSUS: 5DATE:
11/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Josefina BernalTIME COMPLETED:
01:45 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 staff Merly Campos and explained the purpose of the visit. Administrator Josefina Bernal arrived shortly after. There are five (5) ambulatory level 4C developmentally disabled clients in the home. The facility is a single story home located in a residential neighborhood. It consists of 3 client bedrooms, 1 live-in staff room, 2 bathrooms, dining room/family room, kitchen/dining area, living room, outdoor patio, and attached garage. The last fire/emergency drill was conducted on 8/6/2022. Administrator certificate expires 2/25/2023.
OBSERVATIONS:
  • The interior and exterior physical plant was inspected. The facility is equipped with a fire pull alarm system. Smoke and carbon monoxide detectors were tested and operational.
  • COVID-19 Infection Control Practices and signs that promote hand washing, cough/sneeze etiquette, and physical distancing were observed in the entrance, common areas, hallways, bathrooms and client rooms. There is a screening station at the entrance of the facility to screen visitors.
  • The staff room is designated as a COVID-19 isolation room if needed.
  • A posted Emergency Disaster Plan was observed.
  • Three (3) centrally stored client medication records were reviewed. Medications are documented properly and given as prescribed.
  • Staff were observed wearing mask. Clients do not wear masks due to disability exemption.
  • The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food.
  • Water temperature was within normal limits 105 degrees Fahrenheit (40.5 degrees C) and not more than 120 degrees Fahrenheit (48.8 degrees C).
  • Facility has an adequate 30-day+ supply of Personal Protective Equipment (PPEs).
  • All staff have fingerprint clearances.
  • The facility submitted a COVID-19 Mitigation Plan and Infection Control Plan.
  • An Infection Control Plan (ICP) has not been submitted. Submit the ICP as soon as possible A technical assistance advisory note was issued.
NOTE: The cabinet under the kitchen sink was unlocked. Disinfectants and knives/sharps were unlocked. In addition, room #2 has a hole in the wall, and room #3 has a torn door screen, and dirty wall.
Exit interview was conducted with Josefina Bernal. A copy of the report and appeal rights were issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2022
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 3
Document Has Been Signed on 11/17/2022 01:44 PM - It Cannot Be Edited


Created By: Noemi Galarza On 11/17/2022 at 01:08 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 III
FACILITY NUMBER: 198601300

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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, the licensee did not comply with the section cited above in that the cabinet underneath the sink was unlocked. It contained cleaning products and kitchen knives/sharps. The key to the lock was not found; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2022
Plan of Correction
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Administrator agreed to install a lock under the kitchen sink that fits and is able to lock. Please conduct staff training as well. Submit picture proof evidence and staff training by tomorrow.
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: 11/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/17/2022 01:44 PM - It Cannot Be Edited


Created By: Noemi Galarza On 11/17/2022 at 01:08 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 III
FACILITY NUMBER: 198601300

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2022

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 observation, the licensee did not comply with the section cited above in that Room #2 has a hole in the wall, room #3's wall needs to be cleaned and/or painted, and oom #3's sliding door screen is torn; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2022
Plan of Correction
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Administrator agreed to repair the wall in room #2 & room #3, and repairt the sliding door screen in room #3. Submit picture proof evidence 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: 11/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022


LIC809 (FAS) - (06/04)
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