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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601372
Report Date: 10/29/2024
Date Signed: 10/29/2024 11:36:31 AM

Document Has Been Signed on 10/29/2024 11:36 AM - 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:ONE STEP AHEAD DAY PROGRAMFACILITY NUMBER:
198601372
ADMINISTRATOR/
DIRECTOR:		HAMILTON, MARKFACILITY TYPE:
775
ADDRESS:421 DEL MONTE STTELEPHONE:
(626) 794-4103
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 60CENSUS: 36DATE:
10/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:01 AM
MET WITH:Phillip Jackson, Assistant Director TIME VISIT/
INSPECTION COMPLETED:
11:39 AM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced visit for an Annual Inspection. Upon arrival, LPA met with Phillip Jordan (Assistant Director), who assisted with the visit, LPA explained the purpose for the visit. Administrator Mark Hamilton arrived later. The facility is licensed to serve 60 Adults ages 18 and above.

This is a single- story facility located in Pasadena, CA. A tour of the facility includes: a bakery with walk-in freezer and walk in oven, 3 storage closets, 4 client restrooms, 1 staff restroom, 2 staff office rooms, isolation room, activity room, craft room and outdoor shaded activity area.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and cleaning/disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan.
Physical Plant & Environment Safety: Smoke detectors and carbon monoxide detectors are operable and in compliance, there is an emergency sprinkler system throughout the facility. The fire extinguishers were observed and are fully charged. No bodies of water were observed at the facility. The hot water temperature was tested throughout the facility restrooms and measured 73.0 - 132.4 degrees F. All storage areas for cleaning solutions, toxins, poisons and hazardous items are stored in a secured/locked storage closet and inaccessible to clients. There is a shaded rest area provided for the clients. Clients are provided with a non-contaminating water container that is readily available for indoor and outdoor use. The facility toilets require a good cleaning.
Operational Requirements: The facility has the appropriate fire clearance. Staff are knowledgeable on their reporting requirements.

(Continued on 809-C)

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ONE STEP AHEAD DAY PROGRAM
FACILITY NUMBER: 198601372
VISIT DATE: 10/29/2024
NARRATIVE
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Staffing: There appears to be sufficient staffing in the facility. There are at least 2 staff members on duty any time there are clients in the facility. The staff to client ratio is 1 caregiver to 3 consumers.
Personnel Records-Training: Staff files were available electronically during visit. LPA was able to reviewed staff files, during visit.
Client Records-Incident Reports: Client files are kept in a secure location within the staff office and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Consent Forms, and Appraisal Needs & Services Plan. LPA reviewed 5 client records without any issues.
Client Rights-Information: Client Rights Poster is posted within the main office.
Food Service: Pesticides and other similar toxic substances are not stored in food storage rooms or other kitchen areas.
Health Related Services: Staff responsible for providing direct care and supervision maintain training in First Aid and CPR.
Incidental Medical & Dental: Staff have proper training and training is documented within the personnel files. One staff did not have current training on file.
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and relocation sites but needs to be complete and updated.
Emergency Intervention: Clients at this facility have not needed the use of restraints or the use de-escalation techniques.


Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiency observed during today’s visit is documented on the 809-D. Technical advisory provided.

Exit interview was held and a copy of the report was provided to Phillip Jordan, and Mark Hamilton, Administrator.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
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Document Has Been Signed on 10/29/2024 11:36 AM - It Cannot Be Edited


Created By: Alberto Lopez On 10/29/2024 at 11:20 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: ONE STEP AHEAD DAY PROGRAM
FACILITY NUMBER: 198601372

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures 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, the licensee did not comply with the section cited above. Water measure 73.0 - 132.4 degrees F. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/30/2024
Plan of Correction
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Licensee will adjust hot water temperature and keep a log for 7 days and send to LPA as proof of correction.
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:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 10/29/2024 11:36 AM - It Cannot Be Edited


Created By: Alberto Lopez On 10/29/2024 at 11:20 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: ONE STEP AHEAD DAY PROGRAM
FACILITY NUMBER: 198601372

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(3) All toilets, hand washing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in day programs accommodating physically handicapped clients who need such items.

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. 2 toilets were in need of cleaning which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
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Licensee will clean the two (2) toilets and send picture to LPA as proof by POC date.
Type B
Section Cited
CCR
82065.1(d)(1)
Personnel Qualifications and Duties
(1) Direct care staff shall receive a minimum of 8 hours a year of training, documented.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. S1 needs her ongoing yearly training. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
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Licensee will provide the 8 hour minimum training to S1 and send proof to LPA by POC date,
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:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2024


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