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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601815
Report Date: 04/16/2024
Date Signed: 04/16/2024 01:27:00 PM

Document Has Been Signed on 04/16/2024 01:27 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:ALFORD HOMEFACILITY NUMBER:
198601815
ADMINISTRATOR/
DIRECTOR:		SEAN ESTRELLAFACILITY TYPE:
734
ADDRESS:165 ALFORD STTELEPHONE:
(909) 599-7403
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY: 5CENSUS: 5DATE:
04/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Anahi Murillo Serrano- AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of conducting the required annual inspection, using the Compliance and Regulatory Enforcement (CARE) Tool, to evaluate the facility. LPA Maldonado met with Administrator, Anahi Murillo Serrano, and explained the purpose for the visit.

During today's visit, LPA Maldonado conducted a tour of the physical plant with Administrator, observed the facility food supplies, reviewed (5) client medications, (5) client files, (5) staff files, and conducted interviews with (5) staff, and attempted interviews with (4) clients. The facility is a single-story home, operating as an Adult Residential Facility for Persons with Special Health Needs. It is licensed to serve (5) adults, ages 18-59. There is a fire clearance approved for (5) bedridden adults. An approved mitigation plan is in place and Infection Control plan has been submitted to the department for review.

LPA observed all client bedrooms to have the required furniture, sufficient lighting, and closet/storage space. There are (2) full bathrooms and (1) half bathroom in the home- (1) bathroom is designated for client use and accommodates non-ambulatory clients. It is equipped with required grab bars and non-skid mats. The hot water was tested and measured at 99.6*F, which is not within the required temperature of 105*F-120*F. Food supplies was observed and was sufficient as required, considering client's modified/special diets. Fire extinguishers were observed throughout, with current inspections and were fully charged. All sharps and cleaning supplies/toxins were observed to be locked and inaccessible to clients in care. The last fire drill was conducted on 04/04/2024. (5) client files and (5) staff files were reviewed and observed to be complete with all required documentation. (4) client medications were reviewed and were observed to be documented properly and given as prescribed. (2) of (5) clients currently have restricted health conditions, for which the facility maintains and follows all client a written Restricted Health Condition Care Plan, as part of the client's Needs and Services Plans.

During today's visit, deficiencies were observed and will be cited on the LIC9099-D.
An exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE: DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/16/2024
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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Document Has Been Signed on 04/16/2024 01:27 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 04/16/2024 at 01:02 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: 04/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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 in the facility water temperature to measure at 99.6*F and is not in compliance, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2024
Plan of Correction
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Administrator will adjust water temperature and ensures it measures within required temperature. A water log will be completed from 4/16-4/19 and will be submitted to LPA via email 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:Fernando Fierros
LICENSING EVALUATOR NAME:Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:
DATE: 04/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024


LIC809 (FAS) - (06/04)
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