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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602076
Report Date: 08/06/2024
Date Signed: 08/06/2024 02:18:55 PM

Document Has Been Signed on 08/06/2024 02:18 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:EMPOWER UNLIMITED POTENTIALFACILITY NUMBER:
198602076
ADMINISTRATOR/
DIRECTOR:		RAMIREZ, ELLISSETFACILITY TYPE:
775
ADDRESS:6713 SEVILLE AVETELEPHONE:
(323) 770-4440
CITY:HUNTINGTON PARKSTATE: CAZIP CODE:
90255
CAPACITY: 50CENSUS: 38DATE:
08/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:06 AM
MET WITH:Director Ellisset RamirezTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christian Gutierrez conducted an unannounced required annual inspection using the CARE tools. LPA met with Ellisset Ramirez Director and explained the reason for the visit.

This facility is licensed to serve a capacity of fifty (50) Developmentally Disabled Ambulatory Adults, of which ten (10) may be non-Ambulatory. Empower Unlimited Potential is a single-story structure, two buildings consisting of: a kitchen, office, four (4) activity rooms, one (1) client rest room, two (2) beds, three (3) restrooms, reception, and common area, living room area. The Back Building consist of two (2) offices, one (1) classroom, and one (1) bathroom there is also a parking lot behind the main building.

LPA Gutierrez conducted a tour of the facility, reviewed records, and interviewed 3 staff and 3 clients. The following were observed: A total of 38 clients were at the facility during today’s visit with some being out in community. The program site is clean, safe, and in good repair. Disinfectants, cleaning solutions are inaccessible to clients and are locked away. Client’s lunch and snacks are stored in the facility refrigerator. Four (4) bathrooms were observed in good repair, water temperature was tested and not within the required 105–120-degree. Bathroom #1 (B1) 133.7, (B2) 140.7, (B3) 136.3, and (B4) 130.8 deficiency cited. Facility has a fire alarm system with a carbon monoxide detector throughout the facility. Auditory devices on exit doors not working deficiency cited. All rooms were observed to be clean and clear of obstructions. Outside shaded patio area was observed and no potential risks were observed.

SEE LIC 809C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024
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 08/06/2024 02:18 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 08/06/2024 at 01:09 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: EMPOWER UNLIMITED POTENTIAL
FACILITY NUMBER: 198602076

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures 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 three (3) out of three (3) bathrooms BR#1 133.7 BR#2 140.7 and BR#3 136.3 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/07/2024
Plan of Correction
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DSP worker lowered water temperature during visit. Director will test water daily and email LPA water log.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/06/2024 02:18 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 08/06/2024 at 01:09 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: EMPOWER UNLIMITED POTENTIAL
FACILITY NUMBER: 198602076

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82095.5(b)
Infection Control Requirements
(b) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 82022.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above Director did not have Infection Control Plan at facilitywhich poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/20/2024
Plan of Correction
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Director will email LPA Infection Control Plan.
Type B
Section Cited
CCR
82087(a)
Buildings and Grounds
(a) The program site 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, the licensee did not comply with the section cited above three (3) auitory devices on doors did not work IPP for client one (C1) states risk for elopment which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/20/2024
Plan of Correction
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Director will fix current devices on doors or purchase new ones. Director will email LPA with receipts and pictures.
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 Vasallo
LICENSING EVALUATOR NAME:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2024


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Document Has Been Signed on 08/21/2024 08:57 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/21/2024 08:51 AM


Created By: Christian Gutierrez On 08/06/2024 at 01:09 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: EMPOWER UNLIMITED POTENTIAL
FACILITY NUMBER: 198602076

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82087.5(a)(3)
Delayed Egress Devices
(3) Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above no current fire and earthquake drills provided which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2024
Plan of Correction
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Director will conduct fire and earthquake drills with staff and email training to LPA.
Type B
Section Cited
CCR
82068.2(d)(1)
Needs and Services Plan
(d) If the client has an existing needs appraisal or individual program plan (IPP) completed by a placement agency, or a consultant for the placement agency, the Department may consider the plan to meet the requirements of this section provided that: (1) The needs appraisal or IPP is not more than one year old.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in three (3) out of five (5) clients did not have current IPP reports which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2024
Plan of Correction
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Director will email current IPP report to LPA.
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 Vasallo
LICENSING EVALUATOR NAME:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2024


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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: EMPOWER UNLIMITED POTENTIAL
FACILITY NUMBER: 198602076
VISIT DATE: 08/06/2024
NARRATIVE
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Six (6) staff files were reviewed and included Criminal clearance record, CPR/training, and health screening with TB. Five (5) client files were reviewed and included physicians report, TB clearance, three (3) out of five (5) clients were missing individual program plan (IPP)report. Last fire/earthquake drill was conducted in February 2024 deficiency cited. Infectious control plan will be emailed to LPA. There is no medication at facility.

Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided to Elissett Ramirez.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
LIC809 (FAS) - (06/04)
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