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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602037
Report Date: 10/03/2023
Date Signed: 10/03/2023 03:59:00 PM


Document Has Been Signed on 10/03/2023 03:59 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:MORENO FAMILY HOMEFACILITY NUMBER:
198602037
ADMINISTRATOR:BENNY MORENOFACILITY TYPE:
735
ADDRESS:14837 GALE AVE.TELEPHONE:
(626) 968-8420
CITY:HACIENDA HEIGHTSSTATE: CAZIP CODE:
91745
CAPACITY:6CENSUS: 5DATE:
10/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
07:37 AM
MET WITH:Benny MorenoTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 10/03/2023. LPA Ramirez was met by Staff#1 (S1) and explained the purpose of the visit. The facility is licensed serve six (6) developmentally disabled clients 18-59 years old. LPA Ramirez requested and obtained copies of Personnel Report (LIC 500), and Client Roster (LIC 9020). All clients in the home receive services from San Gabriel/Pomona Regional Center.

LPA OBSERVATIONS: Tour began at 08:25 am and was led by S1. The facility is a single-story building located in a residential area with three (3) client bedrooms, one (1) staff bedroom, two (2) bathrooms, kitchen, dining room, living room, attached garage, front yard, and backyard.

Front Yard: LPA Ramirez observed one (1) wheelchair and several black and yellow large plastic storage bins in front of garage door.

Kitchen: LPA Ramirez observed appliances to be in working order. LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located in kitchen cabinet, to be inaccessible to five (5) out of five (5) clients in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants located in garage area, to be inaccessible to five (5) out of five (5) clients in care. LPA Ramirez observed a fully charger fire extinguisher nearby. The kitchen sink water temperature was measured at 120.1 degrees F.

Dining Room/Living room: Dining room was observed to contain one table with plenty of seating. Living room was observed with plenty of lighting. LPA Ramirez observed a fully charged fire extinguisher nearby. LPA Ramirez observed signage promoting cough and handwashing etiquette in this area. LPA Ramirez observed nearby thermostat to read 71 degrees F. LPA Ramirez observed several boxes containing various items were observed stacked in various locations of the living room and dining room area. LPA Ramirez observed this area to be cluttered. LPA Ramirez will issue Type B deficiency.

Linen Closet/Supply Closet/Laundry room: Contained plenty linens, towels, and hygiene products.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023
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: MORENO FAMILY HOME
FACILITY NUMBER: 198602037
VISIT DATE: 10/03/2023
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Client Rooms 1 - 3: LPA Ramirez observed all client bedrooms to contain the required linens, furnishings, and lighting. Client bedroom# 2 dresser is missing third drawer cabinet. LPA Ramirez will issue Type B deficiency. LPA Ramirez was unable to access client bedroom #4 due to client wishes. All client bedrooms are shared.

Bathroom 1-2: Water temperature in client bathroom#1 was measured at 119.6 degrees F which is in the required 105 – 120 degrees F. LPA Ramirez observed signage promoting proper handwashing etiquette near sink. Client bathroom #2, which is located in client bedroom#1, water temperature was measured at 119.3 degrees F. LPA Ramirez observed grab bars in all showers and non slip mats in all bathroom showers. LPA Ramirez observed signage promoting proper handwashing etiquette near sink.

Centrally Stored Medications: LPA Ramirez observed medications to be locked in living room closet. Five (5) client medications administration records were reviewed.

Backyard: No large bodies of water were observed. LPA Ramirez observed semi-sealed and unused patio furniture, plastic black and yellow large storage bins, and other unopened boxes in backyard passageway.

Emergency Drills: Proof of last documented fire drill was on 09/01/23 at 6:00 pm.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide and smoke detectors in hallways. Smoke detectors were observed to be operable during visit.

Staff Personnel Files: Staff files are maintained at the facility. LPA Ramirez reviewed four (4) staff files. LPA Ramirez observed an expired Administrator’s certificate for Benny Moreno with an expiration date of 09/06/21. LPA Ramirez will issue Type B deficiency.

Client Files: Five (5) client files were reviewed.

Infection Control Plan: Licensee will submit inflection control plan within 7 business days to LPA Ramirez via email. LPA Ramirez will issue Technical Assistance.

Exit interview was conducted. Deficiencies and Technical Violations were observed and cited. A copy of this report, 809-D, LIC 9102, and appeals rights was provided.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 10/03/2023 03:59 PM - It Cannot Be Edited

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: MORENO FAMILY HOME
FACILITY NUMBER: 198602037

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2023

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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Based on observation, Livingroom, dining room -contained clutter of boxes and excess of various items stacked up on each other. Third dresser drawer is missing from client bedroom#2, the licensee did not comply with the section cited above in 5 out of 5 clients, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2023
Plan of Correction
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Licensee will remove clutter from living room and dining room area. Licensee will replace or repair client bedroom #2 dresser drawer. Photo proof of corrections must be submitted via email to LPA Ramirez.
Type B
Section Cited
CCR
85064(b)
Administrator Qualifications and Duties
(b) All adult residential facilities shall have a qualified and currently certified administrator.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, current administrator certificate is expired, the licensee did not comply with the section cited above in 5 out of 5 clients, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2023
Plan of Correction
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Administrator will complete all requirements to renew administrators certificate or new administrator shall be designated and required documents shall be submitted to this licensing agency by 10/17/2023. Proof of Administrator Moreno's renewal is required by 10/17/23.
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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5