198601526-5-16-2023-28-AS-CWOG-CRUUAP-20230515152504

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601526
Report Date: 05/15/2023
Date Signed: 05/16/2023 09:58:48 AM

Document Has Been Signed on 05/16/2023 09:58 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	JULSTIN RESIDENTIAL CARE CENTER		FACILITY NUMBER:	198601526
ADMINISTRATOR:	OMAR SAPALARAN		FACILITY TYPE:	735
ADDRESS:	2318 E. WALNUT CREEK PKWY		TELEPHONE:	(626) 862-7207
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91791
CAPACITY: 4		CENSUS: 4	DATE:	05/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Omar Sapalaran		TIME COMPLETED:	03:40 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) Christine Wong conducted the required annual inspection. LPA arrived unannounced and met with Administrator Omar Sapalaran who allowed the entry of the facility and assisted with the visit. The purpose for the visit was explained. The facility is licensed for four non-ambulatory age 18-59. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and here are the domains that LPA inspected: 1, Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting the clients. Staff are cleaning and disinfecting three times a day for high touched surface area. Facility has sufficient PPE supplies and has an Infection Control Plan. 2. Physical Plant and Environmental: The facility is a single story house and located around the residential neighborhood area. The facility includes: kitchen, living room, dining area, four clients bedrooms, two bathrooms, laundry room and a detached garage and staff office. LPA inspected the carbon monoxide detectors and smoke detectors and they are interconnected and located in each clients bedrooms and common area and they are all working well. LPA checked the hot water temperature in bathrooms and tested at 105.2 degrees F which is within Title 22 regulation. All the sharp knives are locked in the kitchen drawer. All the cleaning supplies and chemical are locked under the sink and laundry room and garage and they are inaccessible to clients. The facility has sufficient personal hygiene products for client to use. All clients rooms are furnished, clean and have required beddings. All the bathrooms are clean, sanitize and in a operational condition. 3. Operational Requirements: The facility maintained a fire clearance approved by the fire department which four non- ambulatory client and currently only one client is non-ambulatory. The facility also has a shaded area with table and chairs for client to utilize for outdoor activity. The last fire/disaster drill were conducted on 12/15/22.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

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: JULSTIN RESIDENTIAL CARE CENTER	FACILITY NUMBER: 198601526
	VISIT DATE: 05/15/2023

NARRATIVE

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4. Staffing: The facility has sufficient staffing but the night supervision staff (S1) does not have any planned emergency training.
5. Personnel Record-Training: All the staff files are maintained in the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. The administrator (Omar Sapalaran) certificate expired on 6/2/23. The administrator's HIV and TB Training is updated but will be expired in June 2023.. All the direct care staff has the updated first aid training and Medication Management Training.
6. Clients Right-Information: The facility does not have any client required postural support. The facility does serve adults has internet service shall provide at least one access device.
7. Client Records-Incident Reports: All the client files are maintained in the facility. All the files have the required documents included: admission agreement, updated physician report , Individual Personal Plan (IPP) and functional capacity assessment..etc.
8. Food Service: The facility has two days perishable and seven days non-perishable food supply. The refrigerator is maintained in the required temperature. All the food are stored probably.
9. Health Related Services: All client medication are centrally stored and locked in the kitchen cabinet. All the client's medication are reviewed and they are all accurate and updated.
10. Incidental Medical Services: The facility does not have any client who has the restricted health condition or prohibited health condition.
11. Disaster Preparedness: The facility has an updated emergency disaster plan but staff do not have annual training for emergency and disaster include staff responsibilities. The facility has an updated fire/disaster drill but did not indicate who participate in the drill.
12. Emergency Intervention: All staff have required training including updated CPR training and Pro Act Training.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 1

Exit interview was conducted, Appeals Rights discussed and a copy of the report was given to the administrator Omar Sapalaran

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/16/2023 09:58 AM - It Cannot Be Edited

Created By: Christine Wong On 05/15/2023 at 02:43 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: JULSTIN RESIDENTIAL CARE CENTER	FACILITY NUMBER: 198601526
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85065.6(b)(1)

Night Supervision

(b) Employees providing night supervision from 10:00 p.m. to 7:00 a.m., as specified in (c) through (f) below, shall be available to assist in the care and supervision of clients in the event of an emergency, and shall have received training in the following: (1) The facility's planned emergency procedures. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on the record review, LPA observed the staff#1 did not have any planned emergency procedure training which posed a potential risk to clients in care.
	POC Due Date: 05/29/2023
	Plan of Correction
1 2 3 4	The administrator will ensure staff who provide night supervision shall receive trianing in the facility planned emergency procedures and will send Staff#1 training log to LPA by POC due date

Type B

Section Cited

HSC

1565(b)

Other Provisions

(b) If a facility employs staff, the facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, LPA did not observe any staff have a emergency disaster training annually and staff only had the training while they first hired which posed a potential risk to clients in care.
	POC Due Date: 05/29/2023
	Plan of Correction
1 2 3 4	The administrator will ensure the staff have an emergnecy disaster training annually and send the staff training log to LPA by POC due date.

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:

Christine Wong

LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

LIC809 (FAS) - (06/04)

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