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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601674
Report Date: 05/14/2024
Date Signed: 05/14/2024 02:17:01 PM

Document Has Been Signed on 05/14/2024 02:17 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:FAIRGREEN HOUSEFACILITY NUMBER:
198601674
ADMINISTRATOR/
DIRECTOR:		GEORGE LOPEZFACILITY TYPE:
735
ADDRESS:2051 FAIRGREEN AVETELEPHONE:
(626) 443-1313
CITY:MONROVIASTATE: CAZIP CODE:
91016
CAPACITY: 4CENSUS: 4DATE:
05/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:33 AM
MET WITH:Genny Guadalquivir - AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:04 PM
NARRATIVE
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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 Maria Ramos, Direct Support Professional I & II (DSP I & II) and Alejandra Ramirez, Direct Care Staff and explained the purpose of the visit. Administrator Genny Guadalquivir arrived at 10:25am and assisted LPA with the inspection. The facility is licensed to care for (4) Developmentally Disabled Adults, (3) ambulatory, and (1) non ambulatory, ages 18 through 59. All clients residing at this facility receive case management services provided by San Gabriel Pomona Regional Center. The facility is a level 4I. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained. The staff stated that they use disposable gloves to clean and disinfect the high touched surfaces in the common areas. The facility has submitted a COVID-19 Mitigation Plan and the Infection Control Plan. Bathrooms have hand soap, paper towels, toilet paper. Staff are adhering to infection control requirements.

Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood, contains a total of (4) client bedrooms, (2) bathrooms, a living room, kitchen, dining area, backyard with shaded area, and detached garage. Currently, there are four (4) clients living in the facility. The interior and exterior physical plant was inspected. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, chair and sufficient closet space. LPA observed construction work being done in one of the bedrooms and one of the bathrooms. Only (1) bathroom is working in the home. LPA observed that the dining room is being used as a bedroom for one of the clients due to the renovation work in the bedroom. Administrator stated that an incident report will be submitted today regarding the construction/renovation work. Bathroom has non-skid materials and contained hygiene supplies including liquid soap, and toilet paper. There is a fire place in the living room that is covered and inaccessible to clients. Exit doors are free of any obstruction and there are no pools or large bodies of water. Backyard was inspected and has a shaded area. Laundry area is outside next to the detached garage. There is one (1) fire extinguisher mounted on the wall in the hallway which was 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 reading measured within the required 105 - 120 degrees Fahrenheit. Reading was 116.7 deg F in bathroom #1.

Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. A fire clearance is in place. Surety Bond in the amount of $3000 is in effect and expires on 01/01/2025. Fire and Emergency Preparedness Drill is being conducted on a monthly basis and last drill was conducted on 04/23/2024. *****REPORT CONTINUED ON LIC809-C*****

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
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: FAIRGREEN HOUSE
FACILITY NUMBER: 198601674
VISIT DATE: 05/14/2024
NARRATIVE
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Staffing: A total of fourteen (14) 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 three (3) staff. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Administrator certificate has expired on 11/30/2023 and sent renewal to CCL in October 2023, status is still pending. Administrator has a valid HIV/AIDS training proof at the time of visit.

Client Rights-Information: Client personal rights are posted. Per Administrator, facility provides internet services to all clients and have access to the facility phone. Administrator stated that none of the clients have their own personal cell phone and one (1) client has an IPad. LPA was not able to conduct interviews with the clients as all (4) clients are in the Day Program.

Food Service: There are sufficient food supplies of 2-day perishable and 7-day non-perishable items. The food is properly stored in the refrigerator. Pesticides and cleaning supplies are kept away from the food preparation areas. 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. One of the clients', Client #2 (C2) PRN medication, Lorazepam 0.5 mg tablet was discontinued, but not documented on the MAR. Medications are administered as prescribed by the Physician. Medications are bubbled packed.

Incidental Medical Services: None of the clients at this home has a restricted health condition.

Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan.

Emergency Intervention: Not-Applicable.

Deficiencies cited, 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: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 05/14/2024 02:17 PM - It Cannot Be Edited


Created By: Bennette Pena On 05/14/2024 at 12:08 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: FAIRGREEN HOUSE
FACILITY NUMBER: 198601674

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85087(a)(3)
Building and Grounds
(3) No room commonly used for other purposes shall be used as a bedroom for any person.

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 the dining room is being used as a bedroom for one of the clients due to the renovation work in the bedroom which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 05/24/2024
Plan of Correction
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Administrator will submit photos that the dining room has been cleared and that the area is being used for it's dining purpose. Photos to be submitted 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: 05/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/14/2024 02:17 PM - It Cannot Be Edited


Created By: Bennette Pena On 05/14/2024 at 12:08 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: FAIRGREEN HOUSE
FACILITY NUMBER: 198601674

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)(5)(A)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (A) There is written direction from a physician, on a prescription blank, specifying the name of the client, the name of the medication, all of the information specified in Section 80075(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication of when the physician should be contacted for a medication reevaluation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review, the Administrator did not comply with the section cited above in that one of the clients' (Client #2/C2) PRN medication, Lorazepam 0.5 mg tablet was discontinued, but not documented on the Medication Administration Record (MAR) which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 05/24/2024
Plan of Correction
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Administrator to conduct in service medication documentation training to staff and send copy of the completed, signed in service training form to CCL/LPA by POC due date.

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: 05/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 05/14/2024 02:17 PM - It Cannot Be Edited


Created By: Bennette Pena On 05/14/2024 at 12:13 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: FAIRGREEN HOUSE
FACILITY NUMBER: 198601674

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80086(a)
80086 Alterations to Existing Building or New Facilities

(a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review, the Administrator did not comply with the section cited above in that the Administrator did not notify CCL of the renovation construction being done in one of the client’s bedroom and bathroom which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 05/24/2024
Plan of Correction
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Administrator will submit an incident report (SIR) indicating the details of the renovation project in the facility and submit 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: 05/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024


LIC809 (FAS) - (06/04)
Page: 5 of 5