198601768-4-29-2024-28-AS-SVAD-D4ST9A-20240429143138

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601768
Report Date: 04/29/2024
Date Signed: 04/29/2024 02:31:47 PM

Document Has Been Signed on 04/29/2024 02:31 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	AIDEN HOMES INC		FACILITY NUMBER:	198601768
ADMINISTRATOR/ DIRECTOR:	BENJAMIN BAUTISTA		FACILITY TYPE:	735
ADDRESS:	4209-4211 GRIFFIN AVE		TELEPHONE:	(323) 222-3462
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90031
CAPACITY: 28		CENSUS: 25	DATE:	04/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:03 AM
MET WITH:	Jhoner Rovillos- Care Giver		TIME VISIT/ INSPECTION COMPLETED:	01:30 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) Sanjay Vaid conducted an annual/required visit. Upon arriving at the facility at 9:03AM, LPA met with Staff members / Jhoner Rovillos and Enrique Antiporda who assisted with the visit. The Administrator / Benjamin Bautista arrived 30 minutes later during the visit. LPA explained the purpose of this visit. The facility cares for mentally disabled adults ages 18 - 59. Fire clearance was approved for twenty-eight (28) ambulatory clients. There are no pools or large bodies of water. Passageways and exits are free of obstruction. There is sufficient lighting throughout the facility. The hot water temperature was tested in all the Client bathrooms and measured between 105F - 119F which is within Title 22 Regulations. Clients bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have sufficient closet space. Clients beds have the required linen and the linen is in good repair. Smoke detectors and carbon monoxide alarms are present throughout the facility and were tested at the time of the visit. Kitchen appliances are clean and were operating at the time of the visit. There is sufficient perishable and non-perishable food. The food is also stored properly. The medications are stored in a locked cabinet in the kitchen. Facility is operating within the approved capacity. Facility records were reviewed at 11:44. Five (5) staff files were randomly chosen for review. Staff have criminal record clearances and are associated to the facility. Staff (S1-S5) do not have current first aid certificates and proof of training on file. Two (2) staff (S2 and S4) do not have health screenings with TB information.Admin will update files. Six (6) client files were randomly chosen for review. Files have complete needs and services plans. Clients 5 and 6 (C5-C6) had incomplete medical assessments as they were missing TB information. Negative TB results were present in the client files that were reviewed. Clients have admission agreements completed. Cont on 9099 C

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024

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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: AIDEN HOMES INC	FACILITY NUMBER: 198601768
	VISIT DATE: 04/29/2024

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Clients medications were randomly chosen for review. The medications chosen for review are documented properly and given as prescribed. Mars documentation is not consistence, a few days are missing medication administered. Clients Personal and Incidental (P&I) monies was also reviewed. First Aid kit was fully stocked with current manual. The last disaster drill was conducted on 04/10/2024.

Per CA Code of Regulations, Title 22, and California Health & Safety Code, the deficiencies observed during the visit are documented on 809D. Exit interview held and a copy of the report & appeal rights were provided.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/29/2024 02:31 PM - It Cannot Be Edited

Created By: Sanjay Vaid On 04/29/2024 at 12:19 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: 04/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80070(a)

Constistence Mars documentation. 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 in [2 out of 5] persons which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/13/2024
	Plan of Correction
1 2 3 4	Administrator will train staff on the importance of documenting medication deispensed, will send items covered in training and staff attendance.

Type B

Section Cited

CCR

80066(b)(2)

Ensuring clients files have updated TB clearance records. 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 in 2 out of 5 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/13/2024
	Plan of Correction
1 2 3 4	Administrator will provide list of clients and staff with updated TB clearance records.

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:

Fernando Fierros

LICENSING EVALUATOR NAME:

Sanjay Vaid

LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024

LIC809 (FAS) - (06/04)

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