198601507-8-14-2023-28-AS-CDCN-CUPSLL-20230814135831

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601507
Report Date: 08/14/2023
Date Signed: 08/14/2023 01:58:43 PM

Document Has Been Signed on 08/14/2023 01:58 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:	LOST RIVER HOME		FACILITY NUMBER:	198601507
ADMINISTRATOR:	NAVEEN REDDY		FACILITY TYPE:	735
ADDRESS:	21625 LOST RIVER DR.		TELEPHONE:	(909) 510-9314
CITY:	DIAMOND BAR	STATE: CA	ZIP CODE:	91765
CAPACITY:	4	CENSUS: 4	DATE:	08/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Naveen Reddy, Administrator		TIME COMPLETED:	02:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met with Administrator, Naveen Reddy, and discussed the purpose of today’s visit. The facility is licensed to serve 4 ambulatory developmentally disabled adults and is vendorized by the San Gabriel/Pomona Regional Center. LPA toured the facility and observed the following: Infection Control: Facility staff are still using appropriate hand hygiene and wearing gloves when needed. They continue to clean and disinfect the home daily. Facility has an Infection Control Plan in place. They have sufficient PPE supplies and will be utilizing when deemed necessary. Operational Requirements: The fire clearance is approved for (4) ambulatory clients and there are 4 clients residing at the home. The facility is conducting quarterly drills and are documented. Staff are adhering to operational requirements. Physical Plant & Environment Safety: The facility has 4 Client bedrooms, 1 Administrator office, family/living room, kitchen, and attached garage. There are no pool or bodies of water at the premises. There is one smoke/carbon monoxide combo detector located by the entrance and smoke detectors in each client bedroom. They are all interconnected and operable. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. Staffing: There is sufficient staffing at the facility. Administrator's (Naveen Reddy) renewal certificate was received on 2/8/23 and is pending review from the Department's Administration Bureau. Staff are fingerprint cleared and associated to the facility. Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed 4 staff files. Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file as well as on-going training. LPA did not observe an updated HIV and TB certificate which the administrator shall receiving training every 2 years.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023

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: LOST RIVER HOME	FACILITY NUMBER: 198601507
	VISIT DATE: 08/14/2023

NARRATIVE

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Client Rights-Information: Client rights are posted and included in Client files. There are no clients using postural supports.
Client Records-Incident Reports: LPA reviewed all 4 Client files. They have the required documents such as Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Weight Record, Consent forms, Individual Program Plan/IPP, and Client Rights.
Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. There are no clients on special diets. Plates, cups and utensils are kept cleaned and there are no pesticides or cleaning chemicals stored in the kitchen.
Health Related Services: The medications are centrally stored in the administrator's office. LPA reviewed medication 4 Clients. Medications are administered as prescribed by the Physician and documented on the MAR log.
Incidental Medical Services: There are (0) clients with restricted health condition plan.
Disaster Preparedness: The facility has an Emergency Disaster Plan in place with relocation sites, procedures for sheltering in place, relocation, and emergencies.

A deficiency was issued on the LIC809D. An exit interview was held. A copy of this report and appeal rights were provided to the administrator.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/14/2023 01:58 PM - It Cannot Be Edited

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: LOST RIVER HOME	FACILITY NUMBER: 198601507
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85064(k)

85064(k) Administrator Qualifications and Duties (k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in which the administrator has not renewed the HIV and TB training every 2 years, which poses a potential health and safety risk to persons in care.
	POC Due Date: 08/31/2023
	Plan of Correction
1 2 3 4	The administrator shall obtain a HIV and TB training certificate by 8/31/23.

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: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023

LIC809 (FAS) - (06/04)

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