<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601768
Report Date: 04/12/2022
Date Signed: 04/12/2022 04:48:45 PM

Document Has Been Signed on 04/12/2022 04:48 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:AIDEN HOMES INCFACILITY NUMBER:
198601768
ADMINISTRATOR:BENJAMIN BAUTISTAFACILITY TYPE:
735
ADDRESS:4209-4211 GRIFFIN AVETELEPHONE:
(323) 222-3462
CITY:LOS ANGELESSTATE: CAZIP CODE:
90031
CAPACITY: 28CENSUS: 25DATE:
04/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Eleonor Velasco, staffTIME COMPLETED:
04:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Cynthia Chan conducted an unannounced site visit for the required annual inspection. Upon arrival at the facility, LPA met with Staff, Eleonor Velasco, who assisted with the visit. The facility is licensed to serve 28 ambulatory clients 18 through 59 years of age. There are currently 25 clients residing at the facility. LPA utilized the infection control domain for the inspection and also reviewed medications and food supplies.

LPA Chan toured the entire facility with Staff and observed the following:
* The facility consists of 2 separate buildings. The first building is one story and has a total of 5 rooms, one bathroom, the dining room, and the kitchen. The second building has 2 floors. The first floor consists of 5 client bedrooms, 2 bathrooms, laundry room, living room, and Administrator's office. The second floor consists of 6 bedrooms, 2 bathrooms, and a living room. There are no bodies of water at the facility.
* Coronavirus (COVID-19) signage are posted throughout the facility.
* Per staff, temperature are taken for the clients 2x/day and not consistent with staff.
* Cleaning supplies are stored and locked in the laundry room.
* Food supplies for 2 day perishable and a week of nonperishable were observed.
* The fire extinguishers were last inspected on 11/15/2021.
* The hot water temperature in the communal bathrooms were measured between 105 - 120 degrees F.
* Sufficient PPE supplies are located at the facility.
* The knives located in the kitchen were left unsupervised with the kitchen door open. LPA also observed a knife in the kitchen drawer.
* LPA reviewed medication for 5 randomly selected clients and observed deficiencies for Client #1, where the MAR log indicated the dosage on day 5 or day 6 for all the medications were given. However, LPA observed the medications in the bubble pack for either day 5 or day 6 in all of Client #1's medication. LPA also observed PRN medications unlocked in the kitchen cabinet.
(Continue on LIC809)
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2022
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 7
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: AIDEN HOMES INC
FACILITY NUMBER: 198601768
VISIT DATE: 04/12/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA provided Technical Advisory for the following items:
* N95 Respirators Fit Testing
* Routine screening at entry for all staff, residents, and visitors
* CDSS PINs are available in an accessible location

The deficiencies observed today are cited on the LIC809D form. An exit interview was conducted and a copy of this report, LIC809D, and appeal rights were provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022
LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 04/12/2022 04:48 PM - It Cannot Be Edited


Created By: Cynthia D Chan On 04/12/2022 at 03:35 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: AIDEN HOMES INC
FACILITY NUMBER: 198601768

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(5)(B)
80075 Health Related Services
(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, providing all of the following requirements are met:
(B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above for Client #1 whose medications were observed in the bubble pack for 4/5/22 or 4/6/22 but the MAR indicated client had taken for those days, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/13/2022
Plan of Correction
1
2
3
4
The licensee shall conduct on in-service training with staff to ensure MAR logs are marked accurately and medications are administered appropriately. The training log shall be sent to LPA by POC due date 4/13/22.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 04/12/2022 04:48 PM - It Cannot Be Edited


Created By: Cynthia D Chan On 04/12/2022 at 03:50 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: AIDEN HOMES INC
FACILITY NUMBER: 198601768

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(1)
80075 Health Related Services
k) The following requirements shall apply to medications which are centrally stored:
(1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in that some of the clients' PRN medications were stored in the unlocked kitchen cabinet which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2022
Plan of Correction
1
2
3
4
The licensee shall store all medications in a locked cabinet where it is not accessible to clients. The POC is due on 4/19/22.
Type B
Section Cited
CCR
80087(g)
80087 Buildings and Grounds
(g) 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 met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in that knives were stored in the kitchen countertop and clients may have access to them if left unsupervised, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2022
Plan of Correction
1
2
3
4
The licensee shall ensure that all knives and sharps are stored in a locked area at all times. This POC is due by 4/19/22.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022


LIC809 (FAS) - (06/04)
Page: 7 of 7