198602031-4-23-2024-28-AS-CWOG-D4LQDE-20240423120436

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602031
Report Date: 04/23/2024
Date Signed: 04/23/2024 12:06:12 PM

Document Has Been Signed on 04/23/2024 12:06 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	TOTAL LIFE CARE, INC - EVOLVE SERVICES		FACILITY NUMBER:	198602031
ADMINISTRATOR/ DIRECTOR:	MONTESINOS, JESSICA		FACILITY TYPE:	775
ADDRESS:	545 EREMLAND DRIVE		TELEPHONE:	(626) 257-3235
CITY:	COVINA	STATE: CA	ZIP CODE:	91723
CAPACITY: 60		CENSUS: 24	DATE:	04/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:55 AM
MET WITH:	Nilesh Makwana- Assistant Director		TIME VISIT/ INSPECTION COMPLETED:	12:20 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 Analysts (LPAs) Wong and Daniel Konishi conducted an unannounced annual inspection at the facility. LPAs met with Nilesh Makwana (Assistant Director) and explained the purpose of the visit. The facility is licensed to serve age range 18-59. 60 ambulatory of which 10 maybe non-ambulatory developmentally disabled clients. LPAs utilized the Compliance and Regulatory Enforcement (CARE) Tools which contain the following domains: Infection Control, Physical Plant & Environment Safety, Operational Requirements, Staffing, Personnel Reports-Training, Client Rights - Information, Client Records-Incident Report, Food Services, Health Related Services, Incidental Medical Services, Disaster Preparedness, Emergency Intervention. 1. Infection Control: Facility has an updated infection control plan in place. Facility continues to practice the infection control in the facility. Facility also has sufficient PPE supplies in the facility. 2. Physical Plant and Environmental Safety: The facility is located in residential neighborhood area. The facility includes: office area, reception area, four (4) unisex bathrooms, client kitchen, janitor closet, staff lounge, Art and Music Room, Computer room, Media Room, Envolve Room, Staff kitchen, laundry room, Relaxation/Quiet Room, Education Room, Basic Room, Physical Room, Onsite BCBA office, Conference room, Administrative Office and HR room. LPA inspected the four unisex bathrooms, they are clean and sanitary. The hot water temperature tested between 116.7 and 120 which is within the Title 22 regulation. All the chemicals and cleaning supplies are stored and locked in the janitor closet. All the sharp knives and utensils are stored and locked in the client's kitchen drawers. The facility has a quite room for clients to rest if they do not feel good. The passageway and walkway are free of obstruction. LPA inspected the carbon monoxide detectors and smoke detectors in the facility and they are working well. Facility has drinking water available for client to use.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

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

FACILITY NAME: TOTAL LIFE CARE, INC - EVOLVE SERVICES	FACILITY NUMBER: 198602031
	VISIT DATE: 04/23/2024

NARRATIVE

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3. Operational Requirement: The facility capacity is 60 and which 10 maybe non-ambulatory.
Currently there's about 5 clients are non-ambulatory which is within the fire clearance.

4. Staffing: Facility has sufficient staffing in the facility and the regional center client and staff ratio are 3:1 and usually they have 2 or 2.5 : 1 and the facility does have the required ratio.

5. Personnel Record-Training: All the staff files are stored in the office area cabinet. All the staff in the facility are fingerprint cleared and associated with the facility. All the staff have updated health screening and TB test result. All the staff also have the required 8 hours in service training.

6. Client's Record-Incident Reports: All the client's files are stored in the office area cabinets. All the client have the required documents in their files which included: admission agreement, Individual Program Plan (IPP), face sheet, health screening and doctor order for helmet and gait-belt.

7. Client's Right-Information: Currently the facility has two clients with gait belt and one of them does not have the doctor's order for the gait-belt in file.

8. Food Service: Clients will bring their own snacks and lunch to the day program and facility staff would assist them to heat up the food. Drinking water is available for client in the facility if needed. All the food are stored properly in the client's kitchen and staff kitchen.

9. Health Related Services: The medication is centrally stored and locked in a cabinet in a media room and currently two clients are taking medication in the facility. LPA checked the MARs and the medications were updated and accurate. All facility staff have the updated first aid certificate and they have at least one staff able to perform CPR.

10. Incidental Medical Services: Currently there's one client with restricted health condition. LPA reviewed the client's file and there's an updated Restricted Health Condition Plan in the file and all staff have the required training for the plan.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

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: TOTAL LIFE CARE, INC - EVOLVE SERVICES	FACILITY NUMBER: 198602031
	VISIT DATE: 04/23/2024

NARRATIVE

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11. Disaster Preparedness: The facility has an updated Emergency Disaster Plan (LIC610D) on 4/23/24 and the last fire/disaster drill was conducted on 3/25/24. The facility also has two temporary shelter location.

12. Emergency Intervention: According to the facility staff, facility hasn't used any restraint on client for a long time, the last time probably was 3-4 years ago. If they used restraint, they would follow the protocol that needed.

No deficiencies were observed during the visit but LPA issued two Technical Advice (TA) for facility.

Exit Interview conducted and a copy of the report was provided to Nil Marwana

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

LIC809 (FAS) - (06/04)

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