198601604-6-16-2023-11-AS-PSCT-CSUT7U-20230616142919

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601604
Report Date: 06/16/2023
Date Signed: 06/16/2023 02:29:39 PM

Document Has Been Signed on 06/16/2023 02:29 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	CALIFORNIA MENTOR - 256TH HOME		FACILITY NUMBER:	198601604
ADMINISTRATOR:	MARGARITA NUNEZ RENTERIA		FACILITY TYPE:	735
ADDRESS:	1716 256TH STREET		TELEPHONE:	(424) 263-4028
CITY:	LOMITA	STATE: CA	ZIP CODE:	90717
CAPACITY: 4		CENSUS: 3	DATE:	06/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:09 PM
MET WITH:	Xiomara Vanegas		TIME COMPLETED:	03:00 PM

NARRATIVE

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On 06/16/2023, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced annual required visit using the new CARE Inspection Tool. LPA met with Keisha Lamar, Program Supervisor, and explained the purpose of today’s visit. The facility is licensed to operate for four (4) non-ambulatory developmentally disabled clients of between the ages of 18 through 59. Currently, the home has (3) clients. The clients are Harbor Regional Center clients. One of three of the clients have a Restricted Health Care Condition and none are utilizing postural supports or protective devices. The facilities annual fees are current.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) client rooms, two (2) bathrooms, a living area, a dining area, and kitchen. There is an outside patio area with ample seating and an umbrella used for shade. The laundry area is a room with a door and locked cabinets. There is a detached garage used for storage only.

LPA conducted a records review of (3) client records, (11) staff records, (3) clients Personal & Incidental Records and reviewed the facility disaster plan. All client & Staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (3) Client Medication Administration Records and did not observe any discrepancies at the time of visit.

LPA and Xiomara Vanegas, DSP, toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature met Title 22 standards and measured at 116.9 F. A comfortable temperature was maintained in the facility.

Evaluation Report Continues on LIC 809-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

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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Document Has Been Signed on 06/16/2023 02:29 PM - It Cannot Be Edited

Created By: Perry Scott On 06/16/2023 at 01:50 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: 06/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80066(a)(10)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in 11 out of 11 employee files which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/23/2023
	Plan of Correction
1 2 3 4	Licensee shall submit documentation that the employee files have been updated with a health screening for all staff. Ronald Bautista, Sandrino Enrico, Liz Martinez, Nancy Martinez, Rosana Carranza, Xiomara Vanegas, Dulce Pacheco, Camille Sampillo, Yvvette Velasquez, Luz Lopez, and Lizetth Lopez. Email proof to LPA at perry.scott@dss.ca.gov

Type B

Section Cited

CCR

80066(a)(11)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in 11 out of 11 employee files which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/23/2023
	Plan of Correction
1 2 3 4	Licensee shall submit documentation that the employee files have been updated with a health screening with TB test verification for all staff. Ronald Bautista, Sandrino Enrico, Liz Martinez, Nancy Martinez, Rosana Carranza, Xiomara Vanegas, Dulce Pacheco, Camille Sampillo, Yvvette Velasquez, Luz Lopez, and Lizetth Lopez. Email proof to LPA at perry.scott@dss.ca.gov

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:

Perry Scott

LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CALIFORNIA MENTOR - 256TH HOME	FACILITY NUMBER: 198601604
	VISIT DATE: 06/16/2023

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LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharp objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. There are two (2) fire extinguishers fully charge located in the hallway near the front door and the back door. Smoke detectors and carbon monoxide were operable and in working condition. The last fire/emergency drill was conducted on 5/7/2023.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations (Located in common areas and restrooms). LPA observed that the required postings were posted throughout the facility and the facility has a 60-day supply of Personal Protective Equipment (PPE).

LPA advised the administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing (www.cdss.ca.gov) for Provider Informational Notices (PIN) and for any updates relating to COVID-19 guidance and other related issues.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did observe deficiencies, and therefore citations were issued for personnel records.

An exit interview was conducted, and a copy of this report was provided to Keisha Lamar, Program Supervisor

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

LIC809 (FAS) - (06/04)

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