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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601504
Report Date: 06/11/2024
Date Signed: 06/11/2024 12:40:50 PM

Document Has Been Signed on 06/11/2024 12:40 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:BETH HOUSEFACILITY NUMBER:
198601504
ADMINISTRATOR/
DIRECTOR:		CYNTHIA HARRISFACILITY TYPE:
735
ADDRESS:1260 N. EL MOLINOTELEPHONE:
(626) 791-3448
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 6CENSUS: 6DATE:
06/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:14 AM
MET WITH:Jaqueline Cedillosanchez DSPTIME VISIT/
INSPECTION COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met with DSP worker Jaqueline Sanchez at approximately 9:05 AM and explained the reason for the visit. Acting Administrator Magdalena Estrada arrived shortly.

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



LPA Gutierrez conducted a tour of the facility, reviewed records, and interviewed 2 staff, clients where at day program. The following were observed: Two (2) out of three (3) bedrooms have the required furniture such as bed frames, dressers, lamps, and chairs. Bedroom one (1) did not have required chair TV was given. Bedrooms also have sufficient closet space. Client beds have the required linen. Each bedroom has a smoke detector which were tested. There is a carbon monoxide detector located in the hallway and another in the living room area. The bathrooms were observed to be clean and equipped with grab bars and non-skid mats. The hot water was between 106.6 to 115.3 degrees which is within the required 105 - 120 degrees. There is a fire extinguisher located in the hall and in the laundry room and they are fully charged. Sharps are locked in the kitchen and inaccessible to residents. Cleaning supplies and toxins are locked in kitchen cabinet and inaccessible to residents. First Aid kits were fully stocked with current manuals. There was not a sufficient supply of 2 days perishable food deficiency was cited. Seven (7) days non-perishable foods were observed. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the clients located in the back patio. Passageways and exits are free of obstruction.

SEE LIC 809C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/11/2024
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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Document Has Been Signed on 06/11/2024 12:40 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 06/11/2024 at 11:47 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: BETH HOUSE
FACILITY NUMBER: 198601504

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

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 to supply a minimum of two day perishable food which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/12/2024
Plan of Correction
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Summit proof of food in refrigerator by email with picture or grocery receipt.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/11/2024 12:40 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 06/11/2024 at 11:47 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: BETH HOUSE
FACILITY NUMBER: 198601504

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(b)
Client Records
(b) Each record must contain information including, but not limited to, the following:

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 in one out of five clients which poses/posed a potential health, safety or personal rights risk to persons in care. C4 file did not have admission agreement, medical assesment, conset forms ,TB test and personal rights.
POC Due Date: 06/25/2024
Plan of Correction
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Email all forms by due date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2024


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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BETH HOUSE
FACILITY NUMBER: 198601504
VISIT DATE: 06/11/2024
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Five (5) staff files were reviewed and included Criminal clearance record, CPR/training, and health screening with TB. Five (5) client files were reviewed and four (4) out of five (5) included physicians report, TB clearance, and individual program plan (IPP)report.C4 file was missing physicians report, tb test, admission agreement and consent forms. Last fire/earthquake drill was conducted in May of 2024. Infectious control plan was reviewed. Two (2) staff were interviewed. Five (5) out of (5) client medications were reviewed. Medications are centrally stored and locked MAR log is used.

Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided to Magdalena Estrada.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024
LIC809 (FAS) - (06/04)
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