198601419-6-21-2023-28-AS-CWOG-CSTVLU-20230615163231

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601419
Report Date: 06/15/2023
Date Signed: 06/21/2023 05:26:01 PM

Document Has Been Signed on 06/21/2023 05:26 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:	EMPSON ADULT RESIDENTIAL FACILITY		FACILITY NUMBER:	198601419
ADMINISTRATOR:	SANDRA M. EMPSON		FACILITY TYPE:	735
ADDRESS:	655 SOUTH EASTBURY AVE		TELEPHONE:	(626) 858-2701
CITY:	COVINA	STATE: CA	ZIP CODE:	91723
CAPACITY: 4		CENSUS: 3	DATE:	06/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Sandra Empson		TIME COMPLETED:	04:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Christine Wong conducted the required annual inspection. LPA arrived unannounced and met with the administrator Sandra Empson who allowed the entry of the facility and assisted with the visit. The purpose for the visit was explained. The facility is LICENSED TO SERVE FOUR DEVELOPMENTALLY DISABLED CLIENTS AGES 18-59. AMBULATORY ONLY. LPA Wong utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and here are the domains that LPA inspected: 1. Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting at least once a day and more often for high touched surfaces area. Facility has sufficient PPE supplies and has an Infection Control Plan. 2. Physical Plant and Environmental Safety: The facility is a single story house and located in a residential neighborhood area. The facility includes living room, dining area, three clients bedrooms, administrator bedroom with bathroom, client's bathroom, kitchen, den/TV room, a detached garage and laundry room. The passageways, walkways, driveways and patios are free from obstructions. Bedroom#1 and #3 has one bed, one drawer, one night stand, required bedding and sufficient lighting and closet space. Bedroom#2 has two beds, two drawers, required beddings and sufficient lighting and closet space. The bathroom is clean, sanitary and in a workable condition. The hot water temperature tested in the bathroom was 119.6 degrees F which is within the Title 22 regulation. All the appliances in the kitchen are working properly and all the sharp knives and utensils are stored and locked in the kitchen cabinet. The facility has a land line telephone system on the premises. The facility has ample supply of personal hygiene products and stored at the hallway linen closet and the client's bathroom. 3. Operational Requirements: The facility maintained a fire clearance approved by the fire department which they currently have all three ambulatory clients only. The facility also has shaded area with table and chair for client to utilize for outdoor activity. The last fire and disaster drill was conducted on 02/21/23

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

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: EMPSON ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 198601419
	VISIT DATE: 06/15/2023

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4. Staffing: The facility has sufficient staffing in the facility. The night staff has an updated facility planned emergency procedure training on file.
5. Personnel Records-Training: All staff files are available for LPA to be reviewed in the facility and stored near the living room by the computer. The facility administrator Sandra Empson and her administrator certificate expired on 8/1/2023. Administrator does have an updated HIV and TB training in file. All staff are over 18 years old and they are all fingerprinted and associated with the facility and they all have the required documents in their personnel files. All staff also have an updated first aid training.
6. Clients Right-Information: The facility does not have any client required postural support. The facility does serve adults has internet service shall provide at least one access device.
7. Clients Records-Incident Reports: All clients' files are available to be reviewed in the facility and stored in the file cabinet in the garage. All client files have the required documents which included admission agreement, face sheet, Individual Personal Plan (IPP), updated physician report and functional capability assessment,
8. Food Services: The facility has the minimum of two days perishable and seven days non-perishable food supply in the facility. The refrigerator is maintained in the required temperature. All the food are stored probably.
9. Health Related Services: All client medication are centrally stored and locked in the kitchen cabinet. LPA inspected all three (3) clients medication and they are all seemed accurate and have an updated MARS. . Staff also have required medication management training in their personnel file.
10. Incidental Medical Services: The facility does not have any clients with prohibited health condition or restricted health condition.
11. Disaster Preparedness: The facility has an updated Emergency Disaster Plan and the staff received the training annually. The facility also has at least two available and alternative sites for relocation during emergency.
12. Emergency Intervention: Its not applied to the facility. The facility does not use any restraint for the clients.

No deficiencies were observed during the visit

Exit Interview Conducted and A copy of the report was provided to administrator Sandra Empson

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

LIC809 (FAS) - (06/04)

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