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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601655
Report Date: 04/11/2024
Date Signed: 04/11/2024 12:32:37 PM

Document Has Been Signed on 04/11/2024 12:32 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:WYLAND HOUSEFACILITY NUMBER:
198601655
ADMINISTRATOR/
DIRECTOR:		GEORGE LOPEZFACILITY TYPE:
735
ADDRESS:214 E. WYLAND WAYTELEPHONE:
(626) 443-1313
CITY:MONROVIASTATE: CAZIP CODE:
91016
CAPACITY: 4CENSUS: 4DATE:
04/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Genny Guadalquivir - AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Renee Rodriguez Direct Service Professional I (DSPI) and Sandra Soltero, Care Staff and explained the purpose of the visit. At 10:25am, Administrator Ricardo Montes arrived and at 11:35am, another Administrator, Genny Guadalquivir arrived and assisted LPA with the inspection. The facility is licensed to care for four (4) Developmentally Disabled Adults, ages 18 through 59, (3) ambulatory only and (1) ambulatory clients. All clients residing at this facility receive case management services provided by San Gabriel Pomona Regional Center. LPA observed the following:
Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located near the front door. LPA observed a staff using gloves while cleaning. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Staff are adhering to infection control requirements.
Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan and submitted to CCL. Surety Bond is in effect with bond amount of $3000 and expires on 11/01/2024. Fire/Disaster Drill was last conducted on 03/22/2024.
Physical Plant/Environment Safety: The facility is a single storey home located in a residential neighborhood, contains three (3) client bedrooms, two (2) full bathrooms, living room, kitchen, dining area, den, backyard, and detached garage. Currently, there are four (4) clients living in the facility. Facility is a Level 4I. The interior and exterior physical plant was inspected. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, night stand, light, chair and sufficient closet space. Bathrooms have non-skid materials and contained hygiene supplies including liquid soap, paper towels, and toilet paper. The sink in bathroom #2 is clogged. Exit doors are free of any obstruction and there are no pools or large bodies of water. Backyard was inspected and LPA observed that the outside furniture did not have a patio umbrella. Detached garage was inspected and there is an extra refrigerator/freezer to stock up additional food items. Kitchen knives, sharps objects, are kept locked in a kitchen drawer. The cleaning supplies and toxic substances are stored in a cabinet under the sink which is also kept locked and inaccessible to clients. The facility has a fireplace in bedroom #3 which was screened and inaccessible to clients. There is one (1) fire extinguisher observed mounted on the kitchen wall which was last serviced on 02/01/2024. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. Water temperature readings were within the required 105-120 degrees Fahrenheit. *****CONTINUED ON LIC809-C*****
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2024
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: WYLAND HOUSE
FACILITY NUMBER: 198601655
VISIT DATE: 04/11/2024
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Staffing: A total of twelve (12) staff members including the Administrator provide care and supervision to the clients. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility.
Personnel Records/Staff Training: Reviewed files for four (4) staff. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Administrator certificate expired in Nov. 2023 and submitted renewal to CCL in Oct. 2023.
Client Rights-Information: Client personal rights are posted. Per Administrator, facility provides internet services to all clients and have access to the facility phone. One (1) client has his own personal cell phone and all (4) clients have their own tablets.
Food Service: There are sufficient food supplies of 2-day perishable but insufficient supply of 7-day non-perishable items. Additional food supplies were purchased during the visit. The food is properly stored in the refrigerator. There are zero (0) client with special diets residing at this facility. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.
Client Records-Incident Reports: LPA reviewed Client files for C1 through C4. Client files are maintained at the facility. Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Individual Program Plan (IPP), Behavioral Reports, Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights observed.
Health Related Services The medications are centrally stored and in their original containers. Medications were reviewed for C1-C4 to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubbled packed.
Incidental Medical Services: Per the Administrator, there is no client at this home with incidental medical services nor have a restricted health condition.
Disaster Preparedness: The facility does have a complete Emergency Disaster and Mass Casualty Plan.
Emergency Intervention: Not-Applicable.

Deficiencies cited on LIC 809D. Exit interview, appeals rights and a copy of this report was provided to the Administrator, Genny Guadalquivir.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/11/2024 12:32 PM - It Cannot Be Edited


Created By: Bennette Pena On 04/11/2024 at 12:21 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: 04/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85087.2(b)
Outdoor Activity Space
(b) The outdoor activity area shall provide a shaded area, and shall be comfortable, and furnished for outdoor use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the Administrator did not comply with the section cited above in that LPA observed that the outside furniture did not have a patio umbrella which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 04/18/2024
Plan of Correction
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The administrator shall purchase or locate the patio umbrella to provide outside covered space for the clients in care. Proof that the umbrella was located or purchased shall be sent to CCL/LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024


LIC809 (FAS) - (06/04)
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