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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601506
Report Date: 08/07/2023
Date Signed: 08/07/2023 04:01:01 PM

Document Has Been Signed on 08/07/2023 04:01 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:HARRIET HOUSE ANNEXFACILITY NUMBER:
198601506
ADMINISTRATOR:ANN HAMILTONFACILITY TYPE:
735
ADDRESS:916 CHESTERTELEPHONE:
(626) 791-9215
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 6CENSUS: 6DATE:
08/07/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Staff #1TIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 08/07/2023 at 9:02 am. LPA was met by Staff #1 (S1) and explained the purpose of the visit. The facility is licensed serve developmentally disabled clients 18-59 years old. LPA Ramirez requested and obtained copies of Personnel Report (LIC 500), and Client Roster (LIC 9020).

LPA OBSERVATIONS: Tour began at 9:15 am and was led by LPA Ramirez. The facility is a single-story building located in a residential area with four (4) 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 six (6) out of six (6) clients in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants located in kitchen cabinet to be inaccessible to six (6) out of six (6) clients in care. LPA Ramirez observed S1 wiping down counters and moping the kitchen floor.

Dining Room/Living room: 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 near hallway. LPA Ramirez observed thermostat located in hallway to read 72 degrees F.

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

SEE 809-C for continuation.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2023
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: HARRIET HOUSE ANNEX
FACILITY NUMBER: 198601506
VISIT DATE: 08/07/2023
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Client Rooms 1 - 4: LPA Ramirez observed all resident bedrooms to contain the required linens, furnishings, and lighting. LPA Ramirez observed S2 removing mattress linen from client bedroom # 1 and placing linen in laundry room.

Bathrooms: Water temperature in bathroom#1 located in client bedroom #3, was measured at 116.6 degrees F which is in the required 105 – 120 degrees F. LPA Ramirez observed non-slip mats in this shower. Client bathroom #2 was observed to be clean and water temperature was measured at 113.3 degrees F which is in the required 105 – 120 degrees F. LPA Ramirez observed non-slip mats in this shower. LPA Ramirez observed signs promoting handwashing in both bathrooms.

Backyard: No large bodies of water were observed.

Emergency Drills: Proof of last documented fire drill was conducted 6/21/23 at 10pm and earthquake drill was conducted on 7/11/23 at 7am.

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 maintained at facility. LPA Ramirez was reviewed two (2) staff files for: Health screening, Criminal Record Clearance, Designation of Facility Responsibility, and Administrator’s Certificate for Monique Jordan with an expiration date of 4/6/23. Administrator Jordan was able to provide LPA Ramirez with proof of pending renewal.

Client Files: Six (6) client files were reviewed. Admissions agreements, client 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.

No deficiencies were cited during visit. Exit interview was conducted Administrator Jordan and a copy of this report was provided via email due to printer problems.

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

DATE: 08/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2023
LIC809 (FAS) - (06/04)
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