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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601604
Report Date: 06/21/2021
Date Signed: 06/25/2021 11:10:03 AM

Document Has Been Signed on 06/25/2021 11:10 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:CALIFORNIA MENTOR - 256TH HOMEFACILITY NUMBER:
198601604
ADMINISTRATOR:MARGARITA NUNEZ RENTERIAFACILITY TYPE:
735
ADDRESS:1716 256TH STREETTELEPHONE:
(424) 263-4028
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY: 4CENSUS: 3DATE:
06/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Imani Hood, Program SupervisorTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ana Soto conducted an unannounced Annual inspection visit and infection control inspection to the above facility. LPA was met by Dulce Pacheco, Care Giver and later spoke with Gaby Administrator and also later met with Imani Hood, Program Supervisor and the purpose of today’s visit was explained.

There are currently (3) three Regional Center consumers in placement. (2) clients are non- ambulatory and (1) client is ambulatory. The facility is a single-story structure located in a residential neighborhood. It consists of the following: 4 bedrooms, 2 bathrooms, living room, kitchen, dining room/office, shaded area, indoor and outdoor activity area, laundry room and a detached 2 car garage.

LPA and Dulce toured the entire facility inside and out. Documents are posted as mandated by the DPH and CCLD. Bedrooms 1 - 4 are occupied by clients and contain the mandated furniture. The (2) bathrooms are clean and operational. Smoke detectors and carbon monoxide detector are in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to clients. 1 staff file was not complete, 1 resident file is current along with medications. The water temperature is within 105 - 120 degrees. A comfortable temperature is maintained in the facility. Ample supply of perishable and nonperishable food, linens and personal hygiene supplies are adequate, hazardous toxins and/or items are inaccessible to clients, 2 fire extinguishers are fully charged. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The dining room floor has couple of tiles broken, need to repair.The facility is in good repair. During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry way. LPA observed staff and clients wearing masks, the clients private rooms will be used as isolation room (if needed). The administrator advised LPA that sanitizer is administered to client with the supervision of staff, but sanitizers are not kept in their rooms or in the common areas for safety reasons. The facility has an approved Mitigation plan. Visitors temperatures are checked and logged. The client’s temperatures are checked and logged 2x a day.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2021
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 06/25/2021 11:10 AM - It Cannot Be Edited


Created By: Ana Soto On 06/21/2021 at 03:29 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CALIFORNIA MENTOR - 256TH HOME
FACILITY NUMBER: 198601604

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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80087(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement not met as evidenced by: Based on that the dining room floor has broken tiles. This poses a health and safety which poses a risk for clients.
POC Due Date: 07/05/2021
Plan of Correction
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Administrator will repair the broken tiles in the dining room and send a picture of repair by POC due date sent it by email, fax, and/or mail, LPA Soto.
Section Cited
Deficient Practice Statement
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80033(a)(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. This was not met as evidence by: based on 1 staff file not complete. Whisch poses a health and safety risk for clients.
POC Due Date: 07/05/2021
Plan of Correction
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Administrator will complete file and mail to LPA Soto.
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:Janae Hammond
LICENSING EVALUATOR NAME:Ana Soto
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2021


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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CALIFORNIA MENTOR - 256TH HOME
FACILITY NUMBER: 198601604
VISIT DATE: 06/21/2021
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According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued a citation.

An exit interview was conducted with Imani Hood, Program Supervisor and a hard copy was provided along with Appeal Rights.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021
LIC809 (FAS) - (06/04)
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