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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601504
Report Date: 07/20/2022
Date Signed: 07/20/2022 03:11:23 PM

Document Has Been Signed on 07/20/2022 03:11 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:BETH HOUSEFACILITY NUMBER:
198601504
ADMINISTRATOR:CYNTHIA HARRISFACILITY TYPE:
735
ADDRESS:1260 N. EL MOLINOTELEPHONE:
(626) 791-3448
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 6CENSUS: 4DATE:
07/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Maria Carlos - Administrator TIME COMPLETED:
03:30 PM
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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced annual visit to the facility with focus on infection control domain, food, and medication review. LPA Flores met with Maria Carlos Administrator and explained the reason for the visit.

The facility is licensed to serve 6 ambulatory developmentally disabled adults ages 18 thru 59 years old. Facility is located in a residential area, is a single home consisting of a living room, activity room, a kitchen/dining room, 3 shared client bedrooms, 2 client bathrooms, laundry area, garage area, and cover/sitting area backyard.

LPA conducted a tour of the facility with Maria Carlos Administrator and observed the following:
Living room has a cover fireplace. Activity area and dining room allowed for social distancing. Kitchen was observed and food supplies were observed for at least 2 days of perishables and 7 days of non-perishables. Cleaning supplies and sharps were observed locked in a kitchen cabinet. Medication cabinet was observed in the kitchen and was locked. All clients' bedrooms were observed to have sufficient lightning, furniture, and bedding supplies per regulations. Bathroom #1 and #2 were observed and water was tested as follow bathroom #1 tested at 111.1 degrees F and bathroom #2 tested at 118.3 degrees F., which is within the required 105 - 120 degrees F. LPA reviewed medication and files for 4 clients and 3 staff files. Facility was observed clean and in good condition. Administrator certificate # 6013547735 Expiration 6/18/22, renewal was submitted to the department. Fire extinguishers were observed one in the laundry room and one in the hallway. Smoke/carbon monoxide detectors are interlace and tested during the visit. Facility is currently conducting screening at entry point, has sufficient PPE supplies for at least 30 days, and maintains soap, and hand sanitizer available in bathrooms and bedrooms. Facility does not have signs posted around the facility with visitation guidelines, symptoms, preventive measures, and hand washing signs. Staff has not been fit tested for N95, and trash bins with closed lid were not observed.
Technical Advisories have been provided during this visit. Exit interview was conducted with Maria Carlos and a copy of this report was provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2022
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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