198601300-12-9-2024-28-AS-NGAA-DBSV46-20241209150550

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601300
Report Date: 12/09/2024
Date Signed: 12/09/2024 03:06:04 PM

Document Has Been Signed on 12/09/2024 03:06 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 III		FACILITY NUMBER:	198601300
ADMINISTRATOR/ DIRECTOR:	JOSEFINA R. BERNAL		FACILITY TYPE:	735
ADDRESS:	1916 VALERIE CT		TELEPHONE:	(626) 893-4883
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91792
CAPACITY: 6		CENSUS: 4	DATE:	12/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:01 PM
MET WITH:	Josefina Bernal, Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:10 PM

NARRATIVE

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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit. LPA explained the purpose of the visit to Administrator Josefina Bernal and administrative team. The facility is vendored through San Gabriel Pomona Regional Center as a level 4C ARF for developmentally disabled adults ages 18-59. However, four (4) residents are over the age of 60. Age Exceptions were approved on 1/3/2024. The following 12 (CARE) tool domains were utilized during the inspection.

Infection Control: The facility has an Infection Control Plan on-site.

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. 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 a fire pull-alarm alert system and one (1) fully charged fire extinguishers. Hot water temperature readings measured between the required 105 - 120 degrees Fahrenheit. Storage areas for cleaning solutions/toxins, knives, and hazardous items were inaccessible to clients. *NOTE: the backyard has a large storage shed full of discarded furniture, hazardous solutions, and a loft sleeping area,

Operational Requirements: Fire clearance is approved for four (4) ambulatory and two (2) non-ambulatory residents. Records indicate care and supervision to meet the clients needs is in place. Special equipment and supplies are used by clients. Facility manages residents P & I monies. Facility has a current Surety Bond that expires 9/22/2025.

Staffing: A total of 6 staff members provide care and supervision to the clients.

Personnel Records/Staff Training: Five (5) staff files were reviewed. Criminal background clearance, continuing education of DSP training, 1st Aid/CPR training, and health screening/TB clearance. No emergency training is required.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024

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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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 III	FACILITY NUMBER: 198601300
	VISIT DATE: 12/09/2024

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Resident Rights/Information: Resident Personal Rights poster is posted. Internet access is available for residents. Physician's orders are on file. One (1) resident requires a modified diet.

Resident Records/Incident Reports: Four (4) resident files were reviewed containing admission agreements, Physician's Reports, IPPs, medical/functional assessments, TB clearance, personal rights, medical consent, medication records, and P & I records. Files have been updated with HCBS Tenant/Landlord Rights and Responsibilities Agreement. Four (4) residents have Age Exceptions on file. P & I logs are not updated.

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.

Health Related Services: Residents are assisted with self administration of prescription and non-prescription medications. Medications 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. 30-Day supply of medications were reviewed.

Incident Medical and Dental: Files have Service Plans, updated medical assessments, and COVID-19 vaccination cards on file. Staff training was reviewed.

Disaster Preparedness, and Emergency Intervention: LIC 610D "Emergency Disaster Plan/Disaster and Mass Casualty Plan" is updated.

The last Fire/Emergency Drill was conducted on 8/5/2024 within 6 months of Title 22 requirement.

Emergency Intervention: Facility does not use emergency intervention techniques.

Deficiencies were cited. See LIC 9099D.

Exit interview was conducted with Administrator Josefina Bernal. A copy of the report was issued.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/09/2024 03:06 PM - It Cannot Be Edited

Created By: Noemi Galarza On 12/09/2024 at 02:32 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: 12/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80086(b)

Alterations to Existing Building or New Facilities The licensing agency shall have the authority to require that the licensee have a building inspection by a local building inspector if the agency suspects that a hazard to the clients' health and safety exists. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on physical plant observation, the licensee did not comply with the section cited above in that the backyard has a large storage shed full of discarded furniture, hazardous solutions, and a loft sleeping area, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/18/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator shall contact local Fire Department requesting a building inspection that deems the storage unit safe. Submit proof of inspection report.

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: 12/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 12/09/2024 03:06 PM - It Cannot Be Edited

Created By: Noemi Galarza On 12/09/2024 at 02:47 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: 12/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80026(h)

Safeguards for Cash Resources, Personal Property and Valuables

(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following: 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 all resident cash resource records on site have not been updated since October 2024, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/18/2024
	Plan of Correction
1 2 3 4	Administrator shall ensure that all Personal & Incidental (P&I) funds and logs are updated. Submit a copy of the updated logs.

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: 12/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024

LIC809 (FAS) - (06/04)

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