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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601655
Report Date: 06/13/2022
Date Signed: 06/14/2022 07:54:32 AM

Document Has Been Signed on 06/14/2022 07:54 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:WYLAND HOUSEFACILITY NUMBER:
198601655
ADMINISTRATOR:GEORGE LOPEZFACILITY TYPE:
735
ADDRESS:214 E. WYLAND WAYTELEPHONE:
(626) 443-1313
CITY:MONROVIASTATE: CAZIP CODE:
91016
CAPACITY: 4CENSUS: 4DATE:
06/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Staff / Guadalupe Silva
Health and Services Coordinator / Elsa Montes
Administrator / Genny Guadalquivir		TIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced site visit for the Required - 1 Year inspection. Upon arriving at the facility, LPA met with Staff / Guadalupe Silva and was later joined by the Health and Services Coordinator / Elsa Montes and the Administrator / Genny Guadalquivir who assisted with the visit. The facility is licensed to serve four (4) Developmentally Disabled Clients ages 18 - 59 years. The facility is approved for Three (3) Ambulatory and One (1) Non-Ambulatory Clients. Currently, there are four (4) clients in placement. During today's visit, LPA used the infection control domain to complete the Required - 1 Year inspection. Also, the physical plant was toured, medication and food supplies reviewed.

The facility is located in a residential area. A tour of the single-story facility includes: Three (3) client bedrooms, two (2) bathrooms, recreation room, living room, kitchen, dining area, and indoor/outdoor activity areas. All medications for clients who need assistance are kept locked and inaccessible to other clients.

The bathrooms are clean and operational. Client bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The hot water temperature was tested throughout the facility. The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. All storage areas for toxins and knives are in a secured cabinet and inaccessible to residents. The facility has central air and heating accommodations. LPA reviewed client medications.

Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguisher was observed in the kitchen area and was fully charged. The first-aid kit is fully stocked w/First-aid Manual. The front yard is well landscaped with steps that leads to the entry. A shaded area with chairs is provided in the back yard. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. The outdoor activity area is free of visible hazards and debris and the trash cans have covered lids. There is no evidence of bodies of water (pool) or security bars nor weapons on the premises. The washer and dryer
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2022
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: WYLAND HOUSE
FACILITY NUMBER: 198601655
VISIT DATE: 06/13/2022
NARRATIVE
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are located in the outside patio. There is a detached garage with additional storage of food supply. The garage door is kept locked and inaccessible to the clients at all times.

The following concerns were observed during today's visit;
  • At 10:30am, during a walk through of the physical plant, LPA observed Tide Detergent left accessible to clients in the outside patio, near the washer the dryer. At 11:05am, LPA observed Ajax powder cleanser left accessible to clients inside the cabinet located underneath main bathroom sink.
  • At 11:05am, LPA tested the hot water temperature in the main bathroom and it was measured at 121.2 degrees F. At 11:20am, the hot water temperature inside bedroom 3 was measured at 120.3 degrees F.


The following deficiencies were observed to be in violation of California code of Regulations, Title 22, Division 6 (refer to 809D)
An exit interview was conducted and a copy of this report was provided along with the Appeals Rights.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/14/2022 07:54 AM - It Cannot Be Edited


Created By: Joe Katrdzhyan On 06/13/2022 at 12:06 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: WYLAND HOUSE
FACILITY NUMBER: 198601655

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/13/2022
Section Cited

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Buildings and Grounds. Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not being met as evidenced by:
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At 10:30am, during a walk through of the physical plant, LPA observed Tide Detergent left accessible to clients in the outside patio, near the washer the dryer. At 11:05am, LPA observed Ajax powder cleanser left accessible to clients inside the cabinet located underneath main bathroom sink. This poses an immediate health, safety or personal rights risk to persons in care.
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Type A
06/13/2022
Section Cited

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Furniture, Fixtures, Equipment, and Supplies. 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).
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This requirement is not being met as evidenced by: At 11:05am, LPA tested the hot water temperature in the main bathroom and it was measured at 121.2 degrees F. At 11:20am, the hot water temperature inside bedroom 3 was measured at 120.3 degrees F. This poses an immediate health, safety or personal rights risk to persons in care.
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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:Wei Siew Ho
LICENSING EVALUATOR NAME:Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2022


LIC809 (FAS) - (06/04)
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