198601419-6-6-2024-28-AS-CWOG-D5YSPF-20240606140303

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601419
Report Date: 06/06/2024
Date Signed: 06/06/2024 02:03:56 PM

Document Has Been Signed on 06/06/2024 02:03 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/ DIRECTOR:	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:	06/06/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:15 PM
MET WITH:	Sandy Empson		TIME VISIT/ INSPECTION COMPLETED:	02:20 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. The facility is vendored as a Level 3 Home with San Gabriel and Pomona Regional Center. 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: The facility is a single story house and located in a residential neighborhood area. The facility includes: dining area, kitchen, living room, three client's bedrooms, administrator bedroom and bathroom, den, laundry room and detached garage. For client's bedrooms: Bedroom#1 and #3 has one bed, one chair, one drawer, required furniture and beddings and sufficient closet space and lighting, Bedroom#2 has two beds, two drawers and required furniture and beddings and sufficient lighting and closet space. The client's bathroom is clean, sanitary and in a good working condition. LPA checked the hot water temperature in client's bathroom and tested at 118.9 and it's within Title 22 regulation. The sharp knives and utensils are stored and locked in the cabinet in the laundry room. All the cleaning supplies and chemicals are stored and locked in the cabinet in the laundry room. LPA inspected the carbon monoxide detectors and smoke detectors and they are all working well. All the linen, bedsheets, and personal hygiene products are stored in the hallway closet. The hallway light is always on during night time for client to access the non-private bathrooms. The facility has a telephone service in the premises. The passageway, walkway and patio are free of obstruction. The facility has a hot tub in the backyard but it's covered up by the cover and it's not always using it.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2024

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: EMPSON ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 198601419
	VISIT DATE: 06/06/2024

NARRATIVE

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3. Operational Requirement: The facility is licensed for ambulatory clients only. Currently all the clients are ambulatory in the facility and it's within the fire clearance requirement. The last fire drill was conducted on 5/27/24. The clients can participate the community events if there's an opportunity and chances. The facility backyard has a patio with table and chairs outside for client to utilize the outdoor activity.

4. Staffing: The facility has sufficient staffing in the facility. The administrator is a live in staff and she has the required the facility planned emergency procedure training.

5. Personnel Records-Training: All the staff files are stored in the living room. LPA inspected the staff files and they have the required documents which include employment application, health screening with TB Test result, required training hours and updated First Aid Certificate. The administrator is Sandy Empson and the administrator certificate effective through 8/1/24 and Administrator has the required HIV and TB training certificate.

6. Client's Right-Information: The facility has no client required any postural support. The facility has internet service and provide at least one internet access device with video conferencing for them to communicate with day program, family or primary physician if needed.

7. Food Service: The facility does provide three meals and snacks per day and the facility has sufficient food supply with two days perishable and seven days non-perishable food. All the food are stored properly. Currently there's no client in the facility required any modified diet.

8. Client's Record-Incident Reports: All the client's files are stored in the file cabinet in the garage. LPA inspected all three client's files and they have all the required documents include: Face sheet, admission agreement, functional capability assessment, Updated Individual Program Plan, Updated physician report and TB test result and ambulatory status and medication list. The P&I money and record are stored and locked in the administrator's room. And LPA inspected the P&I record and money and everything is good.

9. Health Related Services: The facility will assist and arrange client for all medical and dental appointments. All the client's medication are centrally stored and locked in the kitchen cabinet. LPA inspected all three client's medication and they seemed to be accurate and updated. They all have 30 days supply of medication. LPA inspected the first aid kit and they all have the required supplies in the kit.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2024

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: 06/06/2024

NARRATIVE

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10. Incidental Medical Services: Currently there's no client is on any restricted health condition plan and no client has any prohibited health condition.

11. Disaster Preparedness: The facility has an updated and complete Emergency Disaster Plan (LIC610D) and they have at least two alternative shelter location.

12. Emergency Intervention: It's not applicable for the facility.

No deficiencies were observed during the visit.

Exit Interview conducted and a copy of the report was provided to the administrator Sandy Empson.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2024

LIC809 (FAS) - (06/04)

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