198601506-6-26-2024-28-AS-DKOI-D6JTB9-20240624143447

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601506
Report Date: 06/24/2024
Date Signed: 06/26/2024 07:06:53 AM

Document Has Been Signed on 06/26/2024 07:06 AM - 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:	HARRIET HOUSE ANNEX		FACILITY NUMBER:	198601506
ADMINISTRATOR/ DIRECTOR:	ANN HAMILTON		FACILITY TYPE:	735
ADDRESS:	916 CHESTER		TELEPHONE:	(626) 791-9215
CITY:	PASADENA	STATE: CA	ZIP CODE:	91104
CAPACITY: 6		CENSUS: 6	DATE:	06/24/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Monique Jordan, Administrator		TIME VISIT/ INSPECTION COMPLETED:	02:45 PM

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Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Required 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to Maria Reynaga, who is a Direct Support Professional at the facility and was granted access into the facility. Administrator, Monique Jordan arrived shortly thereafter and LPA explained the purpose of the visit. There are six (6) ambulatory who reside in the home. The facility is vendored through the Frank D. Lanterman Regional Center.

Infection Control: · Infection control practices and Personal Protective Equipment (PPEs) were observed. LPA observed that the facility had a completed infection control plan.

Physical Plant/Environment Safety:

· LPA conducted a tour of the facility with Monique Jordan, the Administrator and observed the following:

The facility is a one story house located in a residential area and consists of four client bedrooms, two bathrooms, living room, dining room, kitchen/laundry room. There is a large front porch with sufficient shade and seating for client use and a back yard.
· All passageways, walkways, driveway, steps and patio are free from obstructions. The front, back and side areas of the house are free of hazards.
· Fire extinguisher was observed on hallway last reviewed 07/21/2023.
· Smoke/carbon monoxide detectors are tested and in working condition.
· Cleaning supplies are kept locked under kitchen sink away from food supplies.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2024

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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HARRIET HOUSE ANNEX	FACILITY NUMBER: 198601506
	VISIT DATE: 06/24/2024

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· Restroom #1 had a hot water temperature reading measured at 134.4 Degrees F and Restroom #2 measured at 135.5 Degrees F which does not fall between the required 105 Degrees F – 120 Degrees F per Title 22 Regulations.

Operational Requirements:

· The facility is licensed to serve (6) six ambulatory developmentally disabled adults ages 18 thru 59 years old.
· Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires 10/17/2024.
· Surety bond in the amount of $8,000 is current.

Staffing:
· A total of six (6) full-time staff members provide care and supervision to the clients.

Personnel Records / Staff Training:

· Administrator’s certificate expires on 04/06/2025.

· Five (5) staff files were reviewed for criminal background clearance and training.
· Personnel records have health/Tuberculosis (TB) screenings, certifications, and 1st Aid/CPR training.

Client Rights/Information:

· Physician orders were reviewed in client files.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2024

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: HARRIET HOUSE ANNEX	FACILITY NUMBER: 198601506
	VISIT DATE: 06/24/2024

NARRATIVE

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Client Records/Incident Reports:

· Six (6) client files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, nutritional assessments, medication records, and Personal and Incidental (P & I) money were reviewed.

Food Services:

· The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.
· No restricted Health Care plan required for the clients in the facility.

Health Related Services:
· Clients are assisted with self-administration of prescription and non-prescription medications.

· Six (6) centrally stored resident medication records were reviewed. Centrally stored medications are kept in a safe and locked place not accessible to clients in care. Medications are given according to Physician directions.

Incidental Medical and Dental:

· All clients have a Needs and Services Plan, and COVID-19 vaccination cards on file.

· Staff training was on file.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2024

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: HARRIET HOUSE ANNEX	FACILITY NUMBER: 198601506
	VISIT DATE: 06/24/2024

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Disaster Preparedness, and Emergency Intervention:

· A posted Emergency Disaster Plan LIC 610D containing emergency evacuation information was observed.

· An emergency drill was last documented on 06/12/2024.

Emergency Intervention:

· No manual restraints or seclusion are used with clients in care.

Deficiencies were noted on LIC809-D per Title 22 Regulations. Interview was conducted and copy of the report and Appeal Rights were provided to the Administrator.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/26/2024 07:06 AM - It Cannot Be Edited

Created By: Daniel Konishi On 06/24/2024 at 02:01 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: HARRIET HOUSE ANNEX	FACILITY NUMBER: 198601506
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, LPA, Daniel Konishi measured client’s restroom #1 water temperature read at 134.4 degrees F and client’s restroom #2 water temperature read at 135.5 degrees F, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/25/2024
	Plan of Correction
1 2 3 4	Licensee shall immediately adjust water temperature. Licensee to check water temperature at various different times throughout the day and maintain and submit a water temperature log to the LPA for the next 3 days to ensure that hot water temperature falls within 105 degree F and 120 degrees F. Licensee will provide a copy of the log to the department once water temperature falls within Title 22 guidelines.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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:

David Sicairos

LICENSING EVALUATOR NAME:

Daniel Konishi

LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2024

LIC809 (FAS) - (06/04)

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