198601341-7-24-2023-28-AS-BPEA-CU2SPQ-20230724140331

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601341
Report Date: 07/24/2023
Date Signed: 07/24/2023 02:04:11 PM

Document Has Been Signed on 07/24/2023 02:04 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:	CASA RIO HONDO		FACILITY NUMBER:	198601341
ADMINISTRATOR:	PEDRO TRAVIESO		FACILITY TYPE:	735
ADDRESS:	11010 RIO HONDO DRIVE		TELEPHONE:	(562) 928-2807
CITY:	DOWNEY	STATE: CA	ZIP CODE:	90241
CAPACITY: 4		CENSUS: 4	DATE:	07/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:46 AM
MET WITH:	Lourdes Almeida - Assistant Administrator		TIME COMPLETED:	02:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit. LPA met with Henry Lara/Administrator, Lourdes Almeida/Assistant Administrator and explained the purpose of the visit. At 11:45am Claudia Lujan/Senior Admin. arrived with the facility files. The facility is licensed to care for Developmentally Disabled Adults, ages 18 through 59, (4) ambulatory only. All clients residing at this facility receive case management services provided by South Central LA Regional Center. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has submitted an Infection Control Plan. Facility does have COVID-19 signage still posted in the facility. Bathrooms have soap and paper towels. Staff are performing hand hygiene and adhering to infection control requirements.

Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. Surety Bond Insurance (Western Surety Insurance Company) is valid and in effect. Fire clearance was approved for four (4) ambulatory clients only. Fire Drill and Earthquake drill was conducted 3/07/2023. Outdoor/backyard activity area provides a shaded area and furnished for outdoor use.

Physical Plant and Environmental: The facility is a single storey home located in a residential neighborhood, contains a total of (3) client bedrooms and (2) full bathrooms, a living room, activity area, kitchen, dining area, backyard, and attached garage. Currently, there are four (4) clients living in the facility. Facility is Level 4F. The interior and exterior physical plant was inspected. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, and sufficient closet space. Bathrooms have non-skid materials and contained hygiene supplies including liquid soap, paper towels, and toilet paper. Exit doors are free of any obstruction and there are no pools or large bodies of water. Attached garage stores PPE supplies and extra refrigerator/freezer to keep additional food supplies. Kitchen knives, sharps objects, cleaning supplies and toxic substances are locked in a cabinet located in the kitchen and inaccessible to clients. There is one (1) fire extinguisher observed to be fully charged and was last serviced on 6/22/2023. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. There are no cameras in the facility. Water temperature readings measured at 114.4 in bathroom #1 and 118.1 in bathroom #2 and were within the required 105 - 120 degrees Fahrenheit.

*****REPORT CONTINUED ON LIC809-C***

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

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

FACILITY NAME: CASA RIO HONDO	FACILITY NUMBER: 198601341
	VISIT DATE: 07/24/2023

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Staffing: A total of seven (7) staff members plus the Administrator provide care and supervision to the clients. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility.

Personnel Records/Staff Training: Reviewed files for three (3) staff. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Administrator certificate is valid and expiring on 08/25/2023. Administrator has a valid HIV/AIDS training proof at the time of visit. LPA conducted interviews for three (3) staff.

Client Rights-Information: Client personal rights are posted. Facility provides internet services to all clients and have access to the facility phone. None of the clients have personal cell phones and computers/laptop. LPA did not conduct client interviews as they are out in the community.

Client Records-Incident Reports: LPA reviewed Client files for C1 through C3. Client files are maintained at the facility. Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Individual Program Plan (IPP), Behavioral Reports, Functional Assessment, Needs & Services Plan, Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights observed.

Food Service: There are sufficient food supplies of 7-day non-perishable items. LPA observed the food supplies of 2-day perishable to be low. Administrator, Henry Lara stated that today is their grocery day and he will submit a proof of grocery receipt to LPA. The food is properly stored in the refrigerator (clean and well maintained). There are no clients with special diets residing at this facility. Pesticides and cleaning supplies are kept away from the food preparation areas and kept in locked storage room outside. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services: The medications are centrally stored and in their original containers. Medications were reviewed for C1-C2 to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubbled packed. LPA observed that C1's medication was dispensed for bedtime on 7/23/2023 but not recorded properly/not initialed on Medication Administration Record (MAR).

Incidental Medical Services: According to the Administrator, there are no clients at this home with incidental medical services nor have a restricted health condition.

Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan.

Emergency Intervention: Not-Applicable.

Pursuant to Title 22, deficiency was cited on the attached 809D and Technical Assistance were issued. An exit interview was conducted, and a copy of this report was provided to Lourdes Almeida, Assistant Administrator.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/24/2023 02:04 PM - It Cannot Be Edited

Created By: Bennette Pena On 07/24/2023 at 01:17 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: CASA RIO HONDO	FACILITY NUMBER: 198601341
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80075(b)(5)(C)

80075 ...Health Related Services ...(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications....(5) If the client's physician has stated in writing that the client is unable to determine his/her own need...., facility staff designated by the licensee shall be permitted to assist the client with self-administration, providing all of the following requirements are met: ...(C) A record of each dose is maintained in the client's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the client's response. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, and record review, the Administrator did not comply with the section cited above in that C1's bedtime medication Atorvastatin *20 mg was dispensed on 7/23/2023 but staff did not record it on MAR properly which poses an immediate health, safety or personal rights risk to clients in care.
	POC Due Date: 07/25/2023
	Plan of Correction
1 2 3 4	Administrator shall re-train all the staff dispensing medications and submit an in-service medication training which includes topics discussed, signed and dated by all staff members to CCL/LPA by POC due date.

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:

David Sicairos

LICENSING EVALUATOR NAME:

Bennette Pena

LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

LIC809 (FAS) - (06/04)

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