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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601504
Report Date: 07/29/2023
Date Signed: 07/29/2023 06:10:59 PM

Document Has Been Signed on 07/29/2023 06:10 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:BETH HOUSEFACILITY NUMBER:
198601504
ADMINISTRATOR:CYNTHIA HARRISFACILITY TYPE:
735
ADDRESS:1260 N. EL MOLINOTELEPHONE:
(626) 791-3448
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 6CENSUS: 6DATE:
07/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:21 AM
MET WITH:Administrator Maria CarlosTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 07/29/2023 at 11:21 am. LPA was met by Staff #1 (S1) and explained the purpose of the visit. Administrator Maria Carlos arrived to the facility soon after. The facility is licensed serve developmentally disabled clients 18-59 years old. All clients receive services from Frank D Lanterman Regional Center. LPA Ramirez requested and obtained copies of Personnel Report (LIC 500), and Client Roster (LIC 9020).

LPA OBSERVATIONS: Tour began at11:27 am and was led by S1. The facility is a single-story building located in a residential area with three (3) client bedrooms, two (2) bathrooms, kitchen, dining room, living room, front yard, backyard, and detached garage.

Front Yard: Was clean and well maintained. No hazards were observed.

Kitchen: LPA Ramirez observed appliances to be clean and in working order. LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located kitchen cabinet, to be inaccessible to three (3) out of three (3) clients in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants located in bottom kitchen cabinet to be inaccessible to three (3) out of three (3) clients in care.

Dining Room/Living room/Den: Dining room was observed to be clean and contained one table with plenty of seating. Living room was observed plenty of seating and lighting. LPA Ramirez observed fully charged fire extinguisher in dining room closet. Den was observed to be clean and contain plenty of seating and lighting.

Linen Closet: Contained plenty linens, towels, and hygiene products.

SEE LIS 809-C for continuation.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7
Document Has Been Signed on 07/29/2023 06:10 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 07/29/2023 at 12:54 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: BETH HOUSE
FACILITY NUMBER: 198601504

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, right side of medication cabinet lock was missing, the licensee did not comply with the section cited above in 3 out of 3 clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/30/2023
Plan of Correction
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Licensee will repair medication cabinet lock. S1 removed all medications in this cabinet and moved to another secure location. Licensee will provide photo proof of correction via email. Picture proof must be submitted by 8/8/23.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2023


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 07/29/2023 06:10 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 07/29/2023 at 12:54 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: BETH HOUSE
FACILITY NUMBER: 198601504

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, private client bathroom #1 shower door was missing handle, the licensee did not comply with the section cited above in 1 out of 3 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2023
Plan of Correction
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Licensee will repair shower door handle in private client bathroom #1. Licensee will send photo proof via email.
Type B
Section Cited
CCR
80066(a)(12)(B)1
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) For employees that are required to be fingerprinted pursuant to Section 80019: (B) Documentation of either a criminal record clearance or exemption as required by Section 80019(e). 1. For Certified Administrators, a copy of their current and valid Administrator Certification meets this requirement.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, Administrator Maria Carlos, could not provide copy of current Administrator Certificate, the licensee did not comply with the section cited above in 3 out of 3 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2023
Plan of Correction
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Licensee will send photo proof of current Administartor Certificate via email.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2023


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 07/29/2023 06:10 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 07/29/2023 at 12:54 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: BETH HOUSE
FACILITY NUMBER: 198601504

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(e)
Personnel Records
(e) All personnel records shall be maintained at the facility site.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, staff files were not available at the facility and staff could not access files at LPA Ramirez's request, the licensee did not comply with the section cited above in 3 out of 3 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2023
Plan of Correction
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Licensee will develop plan to address how staff files will be made accessible when requested by this licensing agency. Must email plan to LPA Ramirez.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2023


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: BETH HOUSE
FACILITY NUMBER: 198601504
VISIT DATE: 07/29/2023
NARRATIVE
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Client Rooms 1 - 3: LPA Ramirez observed all resident bedrooms to contain the required linens, furnishings, and lighting. LPA Ramirez did observe four (4) extra mattress protectors in linen closet. LPA Ramirez observed Client #1 (C1) wearing a black helmet while sitting in a chair in C1’s bedroom. LPA Ramirez could not locate a physician order for the use of C1 wearing a helmet. LPA Ramirez did review C1’s file. LPA Ramirez reviewed C1’s most recent Individual Personal Plan (IPP) and it indicates C1 uses a helmet. LPA Ramirez will issue Technical Violation.

Bathrooms: Water temperature in Private bathroom#1 located in client bedroom #1, was measured at 113.7 degrees F which is in the required 105 – 120 degrees F. LPA Ramirez observed shower door handle to be missing. LPA Ramirez observed grab bars and non-slip mats in this shower. Shared bathroom #2 was observed to be clean and water temperature was measured at 116.7 degrees F which is in the required 105 – 120 degrees F. LPA Ramirez observed grab bars and non-slip mats in this shower.

Centrally Stored Medications: LPA Ramirez observed right cabinet door missing locking mechanism. LPA Ramirez observed several different client medications to be accessible to three (3) out of three (3) clients in care, and visitors.

Backyard: No large bodies of water were observed.

Emergency Drills(Conducted every 6 months): Proof of last documented fire drill was conducted 3/01/23.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide and smoke detectors in hallways. Smoke detectors were observed to be operable during visit.

Staff Personnel Files: Staff files were not maintained at facility. LPA Ramirez was unable to view current Administrators’ certificate.

Client Files: Three (3) client files were reviewed. Admissions agreements, resident personal rights, and recent (2023) Individual Personal Plan (IPP) were observed in files.

Infection Control Plan: Licensee will submit updated copy of Infection Control Plan to LPA Ramirez by 8/8/23 or LPA Ramirez may return to issue deficiency.

Deficiencies are being cited. Two (2) technical Violations was issued during visit. Exit interview was conducted Administrator Carlos and a copy of this report, 809-D, LIC 9102 TV, and appeals rights were provided via email due to printer problems.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2023
LIC809 (FAS) - (06/04)
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