198601885-7-20-2023-28-AS-EIRA-CTWSUS-20230720141138

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601885
Report Date: 07/20/2023
Date Signed: 07/20/2023 02:11:43 PM

Document Has Been Signed on 07/20/2023 02:11 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:	GRAYBURN HOME		FACILITY NUMBER:	198601885
ADMINISTRATOR:	ELAINE MILLER		FACILITY TYPE:	735
ADDRESS:	2973 GRAYBURN ST		TELEPHONE:	(909) 596-5360
CITY:	POMONA	STATE: CA	ZIP CODE:	91767
CAPACITY:	4	CENSUS: 4	DATE:	07/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Irene Gallardo and LaTonya King		TIME COMPLETED:	02:30 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) Elizabeth Irra conducted the required annual inspection. LPA met with Irene Gallardo and discussed the purpose of today’s visit. LaTonya King (Administrator) arrived at approximately 11:15 A.M.. This is a single home with (4) bedrooms, (2) bathroom, living room, kitchen, dining area and an attached garage. Fire Clearance is for (1) Ambulatory and (3) Non-Ambulatory. Each client has their own bedroom. All clients from this home receive case management services provided by San Gabriel Pomona Regional Center. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: Last Disaster Drill was conducted on 07/14/23. Staff are adhering to operational requirements. Physical Plant & Environment Safety: Smoke alarms were tested and operable. Fire extinguishers are located in the kitchen and hallway and were last serviced on 06/16/23. Carbon monoxide detectors are combined with the smoke alarms (tested and operable). Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. Water temperature measured at: 108.8* kitchen and 110.0* in the bathroom near the laundry room and hallway bathroom. Refer to LIC 809C for the continuation of this report.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GRAYBURN HOME	FACILITY NUMBER: 198601885
	VISIT DATE: 07/20/2023

NARRATIVE

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Staffing: There is sufficient staffing at the facility. Administrator Certificate for LaTonya King expires 09/26/24. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Staff #1 (S-1) and Staff #4 (S-4). Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Staff have on-going training.

Client Rights-Information: Client rights are posted and included in Client files. Per Administrator, there are no clients using postural supports.

Client Records-Incident Reports: LPA reviewed Client files for Client #1 (C-1) through Client #4 (C-4). Client files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Weight Record, Functional Capabilities Assessment, Consent For Medical Treatment, Individual Program Plan (IPP), House Rules, and Client Rights were observed.

Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. Per Administrator, there are no clients on special diets. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services: The medications are centrally stored and bubbled packed. LPA reviewed medication for C-1 through C-4. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician.

Incidental Medical Services: Per Administrator, there are (0) clients with restricted health condition plan.

Disaster Preparedness: The facility has an Emergency Disaster Plan (LIC610D/9 pages) is in place.

Exit interview, appeals rights and a copy of this report was provided to LaTonya King.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

LIC809 (FAS) - (06/04)

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