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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601975
Report Date: 10/17/2023
Date Signed: 10/17/2023 05:06:25 PM

Document Has Been Signed on 10/17/2023 05:06 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:C & N GROUP CORPORATIONFACILITY NUMBER:
198601975
ADMINISTRATOR:CHRISTOPHER SORTOFACILITY TYPE:
735
ADDRESS:1249 N ARMELTELEPHONE:
(626) 498-0409
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY: 6CENSUS: 5DATE:
10/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Staff#1TIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection. The facility is licensed to serve six (6) Non-Ambulatory clients, (age 18-59). LPA met with staff#1. San Gabriel Pomona Regional Center provides case management service to clients residing in this home. LPA discussed the purpose of today's visit. Facility annual fee is current.

During the visit, LPA applied the CARE tool, interviewed staff and clients, toured the facility, checked food supply and reviewed medications. The home is located in a residential neighborhood within the city of Covina and is a single-family house which consists of a living room, attached garage/storage, dining area, kitchen, three (3) client bedrooms and two (2) bathrooms. The required two (2) days perishable and seven (7) days non- perishable were observed. Clients’ bedrooms had the required furnishing and in compliance. Adequate linen and personal hygiene supply were observed. Smoke detectors were combined with carbon monoxide detectors are operational. Last fire drill was conducted on 10/01/23. Fire extinguisher was fully charged. Sharp items such as knives are locked in the kitchen cabinet. Hot water temperature measured at 115.5 degrees Fahrenheit which in compliance with Title 22 regulations. Pesticides/poisons were not stored in food areas, kitchen, or where kitchen equipment/utensils were stored. Medications were centrally stored, locked in a storage room, and medication records were properly logged and current.

Deficiencies were cited per California Code of Regulations, Title 22, Division 6. An exit interview was conducted with staff#1 at the facility and discussed citations with Administrator, Christopher Sorto over the phone. A copy of the report and appeal rights were provided to staff#1
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2023
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 4
Document Has Been Signed on 10/17/2023 05:06 PM - It Cannot Be Edited


Created By: Bonnie Tao On 10/17/2023 at 04:16 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: C & N GROUP CORPORATION
FACILITY NUMBER: 198601975

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above (1) the bathroom next to client#4 had a sink which is clogged and (2) the bathroom next to client #3 had a shower area which the water switch/handle is missing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2023
Plan of Correction
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Licensee agreed to fix the bathroom shower handle and clogged sink by the due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Fernando Fierros
LICENSING EVALUATOR NAME:Bonnie Tao
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/17/2023 05:06 PM - It Cannot Be Edited


Created By: Bonnie Tao On 10/17/2023 at 04:25 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: C & N GROUP CORPORATION
FACILITY NUMBER: 198601975

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(c)
Personnel Records All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not maintain staff records in the facility to comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/20/2023
Plan of Correction
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Licensee agreed to update and maintain staff records in the facility by the POC due date. Staff records include FIRST AID CERTIFICATE; FINGERPRINT CLEARANCES/EXEMPTIONS; EDUCATION VERIFICATION; LIC501: PERSONNEL RECORD OR JOB APPLICATION; LIC503: HEALTH SCREENING; LIC508: CRIMINAL RECORD STATEMENT; LIC9052: EMPLOYEE RIGHTS; MTV: MEDICAL TRAINING VERIFICATION & TB TEST results
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Fernando Fierros
LICENSING EVALUATOR NAME:Bonnie Tao
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/17/2023 05:06 PM - It Cannot Be Edited


Created By: Bonnie Tao On 10/17/2023 at 04:53 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: C & N GROUP CORPORATION
FACILITY NUMBER: 198601975

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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2
3
4
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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:Fernando Fierros
LICENSING EVALUATOR NAME:Bonnie Tao
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2023


LIC809 (FAS) - (06/04)
Page: 4 of 4