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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601815
Report Date: 04/07/2023
Date Signed: 04/07/2023 02:54:50 PM

Document Has Been Signed on 04/07/2023 02:54 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:ALFORD HOMEFACILITY NUMBER:
198601815
ADMINISTRATOR:SEAN ESTRELLAFACILITY TYPE:
734
ADDRESS:165 ALFORD STTELEPHONE:
(909) 599-7403
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY: 5CENSUS: 5DATE:
04/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:39 AM
MET WITH:Efnan Scott, AdministratorTIME COMPLETED:
03:03 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted an annual required visit. LPA met with Administrator, Efnan Scott and explained the reason for the visit. The facility cares for adults with special health care needs and is vendorized by San Gabriel/Pomona Regional Center. The fire clearance is approved for 5 bedridden residents.

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 residents and medications. Disposal of trash are done immediately after changing a client. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and but does no have an Infection Control Plan posted by the entrance.
Operational Requirements: The facility has plan to accept or retain clients with special health needs. There are currently 5 bedridden clients resident residing at the facility. The facility has enough liability insurance covering injury to clients and visitors.
Physical Plant & Environment Safety: . There are 5 bedrooms, 4 bathrooms, living room, dining room, kitchen, staff office and a attached garage. All rooms have required furniture. Facility has operable smoke and carbon monoxide combo detectors located in each room and hallway. Knives, cleaning solutions, and disinfectants are locked in the cabinets. No firearms or weapons are stored at the facility. LPA measured the hot water temperature in the bathroom sink and shower. The hot water temperature in the bathroom and shower were measured between 104.0 – 105.1 degrees F of which 104.0 is not within the required range of 105-120 degrees.
Staffing: There appears to be sufficient staffing at the facility. The administrator’s Efnan Scott expires 07/25/2024 Staff employed are all over the age of 18.
Continued on 809C
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2023
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
Document Has Been Signed on 04/07/2023 02:54 PM - It Cannot Be Edited


Created By: Alberto Lopez On 04/07/2023 at 02:13 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: ALFORD HOME
FACILITY NUMBER: 198601815

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. The water measured between 104.0 to 105.4 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2023
Plan of Correction
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Administrator will adjust water temperature and send proof to LPA by POC date.
Type A
Section Cited
CCR
80069(b)
Clients Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 3 out of 5 persons who did not have LIC602 on file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/12/2023
Plan of Correction
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Administrator will obtain current LIC602 for 3 clients that are missing the report in their files and send proof to LPA by POC 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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2023


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 04/07/2023 02:54 PM - It Cannot Be Edited


Created By: Alberto Lopez On 04/07/2023 at 02:13 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: ALFORD HOME
FACILITY NUMBER: 198601815

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80023(a)
Disaster & Mass Casualty Plan
(a) Each licensee shall have and maintain on file a current, written disaster and mass casualty plan of action.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above. Facility did not have disaster plan on file during visit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/12/2023
Plan of Correction
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Administrator will create emergency disaster plan and submit to LPA for approval by POC 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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 04/07/2023 02:54 PM - It Cannot Be Edited


Created By: Alberto Lopez On 04/07/2023 at 02:13 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: ALFORD HOME
FACILITY NUMBER: 198601815

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)(5)
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 5 of 5 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/12/2023
Plan of Correction
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Administrator will obtain PRN authorization letters for all 5 clients and send proof to LPA by POC 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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2023


LIC809 (FAS) - (06/04)
Page: 4 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: ALFORD HOME
FACILITY NUMBER: 198601815
VISIT DATE: 04/07/2023
NARRATIVE
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Personnel Records-Training: Staff files are maintained at the facility. Staff have current CPR/first aid training which includes sufficient on-going training.
Health Related Services: Clients are assisted with medication administration and incontinent services and has plan to reposition clients.
Client’s Records-Incident Reports: Client files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Pre-admission appraisal/appraisal Needs & Services Plan. Three client files are missing current Physicians report.
Client’s Rights-Information: The Complaint poster and client’s personal rights are posted at facility. Visiting hours are posted near the entrance.
Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet client's physical capability.
Food Service: There are sufficient food supplies of 2-day perishable and a week (7 days) of non-perishable items. The food is properly stored in the refrigerator to avoid cross contamination.
Incidental Medical & Dental: The medications are centrally stored and in their original containers. During the visit today, LPA reviewed 4 client’s medication and did not observe PRN letters on file.
Disaster Preparedness: The facility does not have an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Last emergency drill was conducted March 3rd, 2023
Clients with Special Health Needs: The facility accepts and retains clients with developmental disabilities and is vendorized by San Gabriel/Pomona Regional center. The staff received training on appropriately caring for residents with developmental disabilities and receiving oxygen. No Smoking - Oxygen in use signs are posted on the doors of residents using oxygen.

During the visit today, LPA observed some deficiencies and are indicated on the LIC809D. Technical advisories were also provided. An exit interview was held. A copy of this report, LIC809D, technical advisory notes, and appeal rights were given to Co-Administrator Efnan Scott
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023
LIC809 (FAS) - (06/04)
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