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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602080
Report Date: 09/15/2023
Date Signed: 09/15/2023 03:27:27 PM

Document Has Been Signed on 09/15/2023 03:27 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:HOURGLASS HOMEFACILITY NUMBER:
198602080
ADMINISTRATOR:MARIA BINOTAPAFACILITY TYPE:
735
ADDRESS:1121 HOURGLASS PLACETELEPHONE:
(909) 631-8521
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY: 6CENSUS: 6DATE:
09/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Simon Shamon, StaffTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the unannounced annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met with Staff, Simon Shamon, and explained the purpose of the visit. Administrator, Maria Binotapa, arrived shortly thereafter to assist with the visit. The clients receive services from the San Gabriel/Pomona Regional Center.

LPA inspected and observed the following:
Infection Control: The facility is continuing to clean and disinfect daily. They are wearing gloves when necessary to assist clients and performing hand hygiene. Facility has submitted an Infection Control Plan.
Physical Plant & Environment Safety: The facility consists of 3 Client bedrooms, 1 Staff office, 2 bathrooms, living room, family room, kitchen, laundry area, and garage. The bedrooms are equipped with the required furnishings. Each client bedroom has a smoke/carbon monoxide combo detector. Knives and cleaning solutions are locked under the kitchen sink. There are no firearms or weapons stored at the facility and no swimming pool. There are extra hygiene supplies and clean linens observed.
Operational Requirements: The fire clearance is approved for (6) ambulatory clients. Staff are providing the care and supervision as necessary to meet the client's needs.
Staffing: There is sufficient staffing at the facility. Administrator (Maria Binotapa) Certificate expires 8/6/24 and the HIV/TB training are still current. Staff employed are fingerprint cleared and associated to the facility. Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed files for 4 Staff. Staff files have current First Aid/CPR certification, Health Screening with TB test results, Employee Rights form, and on going training.
Client Rights-Information: There are no clients using postural supports. Clients are given internet service and devices to use.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2023
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: HOURGLASS HOME
FACILITY NUMBER: 198602080
VISIT DATE: 09/15/2023
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Client Records-Incident Reports: LPA reviewed 5 Client files. The files include the Admission Agreement, Physician's Report, Weight Record, Consent forms, current Individual Program Plan, Client Rights form, and Safeguarding forms for cash and inventories.
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. Kitchen is kept clean.
Health Related Services: The medications are centrally stored in the locked closet. LPA reviewed medications for 5 Clients. The facility uses the Medication Administration Record (MAR) log to document medications given and are administered as prescribed by the Physician.
Incidental Medical Services: There are no clients with prohibited or restricted health conditions.
Disaster Preparedness: Emergency contact numbers are readily available. The emergency disaster plan has at least 2 relocation sites, location of shutoff valves, and procedures.

There are no deficiencies issued today. An exit interview was held. A copy of this report was given to the administrator.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023
LIC809 (FAS) - (06/04)
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