198601668-3-22-2024-28-AS-THEA-D3LUNB-20240322154339

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601668
Report Date: 03/22/2024
Date Signed: 03/22/2024 03:44:44 PM

Document Has Been Signed on 03/22/2024 03:44 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:	CASA MENENDEZ		FACILITY NUMBER:	198601668
ADMINISTRATOR:	RAFAEL MENENDEZ		FACILITY TYPE:	735
ADDRESS:	8521 STEWART & GRAY RD.		TELEPHONE:	(562) 381-0000
CITY:	DOWNEY	STATE: CA	ZIP CODE:	90241
CAPACITY: 4		CENSUS: 4	DATE:	03/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:21 PM
MET WITH:	Samira Menendez - Administrator		TIME COMPLETED:	04:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Tena Herrera conducted the required unannounced annual inspection. LPA met with Christina Jimenez (Caregiver) and explained the reason for the visit, shortly after Administrator Samira Menendez arrived to assist with the visit. The facility is licensed to serve (4) Ambulatory Adults, ages 18 through 59. Facility currently has 4 Ambulatory clients serviced by South Central Los Angeles Regional Center.

The facility is a single-story home located in a residential area in Downey, Ca. A tour of the facility includes: living room, dining area, kitchen, 2 client bedrooms, 1 bathrooms, detached garage (with laundry), front yard and back yard.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility.
Physical Plant & Environment Safety: LPA toured facility, clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested in the client bathrooms and was within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked cabinet under kitchen sink and are inaccessible to clients. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged.
Operational Requirements: Staff have proper training to meet the needs of the clients in care. Facility has an activity area furnished for outdoor use. Last fire/earthquake drill was conducted on 7/2023.
(Continued on 809-C)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024

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: CASA MENENDEZ	FACILITY NUMBER: 198601668
	VISIT DATE: 03/22/2024

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Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the clients in the case of an emergency.
Personnel Records-Training: Staff files are maintained in a secure location. LPA reviewed 4 staff files during today’s visit, files reviewed contained the following: Criminal Background Clearance, First-Aid/CPR/AED/CPI and sufficient on-going training. There are 3 administrators at this facility, Administrator Samira Villalobos has a valid administrator certificate that expires on 9/15/2025.
Client Rights-Information: Facility provides telephone landline and internet for the clients. Client rights posters and reporting posters are displayed within the facility.
Client Records-Incident Reports: Client files are maintained in a secured locked cabinet and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. LPA reviewed 4 client files with no issues.
Food Service: 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.
Health Related Service: Staff designated to administer medication have the proper annual training on file. Medication is properly labeled and are centrally stored in a locked cabinet and are in their original containers. Incidental Medical & Dental: All training is documented in the facility personnel files. Staff performance is reviewed annually, and documentation is maintained in the personnel files.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Facility maintains documentation of the required emergency drills, however, during visit LPA observed last drill conducted on 7/2023 which is not within regulation, details will be cited on the 809-D.
Emergency Intervention: Clients at this facility do not need the use of restraints or de-escalation techniques, however, staff maintain a valid CPI certificate.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during todays visit will be documented on the 809D.

Exit interview was held and a copy of the report and appeal rights will be emailed to Administrator Samira Menendez.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/22/2024 03:44 PM - It Cannot Be Edited

Created By: Tena Herrera On 03/22/2024 at 03:32 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: CASA MENENDEZ	FACILITY NUMBER: 198601668
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1565(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above the last fire/emergency/earthquake drill was conducted in July 2023, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/05/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator to conduct a fire/emergency/earthquake drill and submit a copy of the log with participants to LPA via Email by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Tena Herrera

LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024

LIC809 (FAS) - (06/04)

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