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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602156
Report Date: 04/18/2023
Date Signed: 04/18/2023 03:49:07 PM

Document Has Been Signed on 04/18/2023 03:49 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:DEL SOL HOME (CALIFORNIA)FACILITY NUMBER:
198602156
ADMINISTRATOR:GONZALES, HEINRICHFACILITY TYPE:
735
ADDRESS:17012 CALIFORNIA AVENUETELEPHONE:
(562) 804-4294
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 4CENSUS: 4DATE:
04/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:51 AM
MET WITH:Janice Diaz, DSPTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to Bianca De La Cruz a DSP staff. Assistant Administrator Jorgelle Catunao arrived shortly after. There are three (3) non-ambulatory developmentally disabled clients as well as one (1) ambulatory client in the home. The facility is an Adult Residential Facility (ARF) vendored by Harbor Regional Center.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention.

Infection Control:

· Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station at the entrance of the facility. Bedroom #2 is designated as a COVID-19 isolation room if needed. The facility had an Infection Control Plan and emailed it to the LPA for documentation.


Physical Plant/Environment Safety:

· The facility is a single-story home located in a residential neighborhood that is licensed for four (4) non-ambulatory clients. It consists of 4 client bedrooms, a living room, dining room, a medication storage room, a kitchen, 2 (two) bathrooms of which only one is in-use, backyard patio area, and an attached garage.


· The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors are operational. The facility has one (1) fully charged fire extinguisher. Cleaning supplies and toxic substances are inaccessible to clients.
· Water temperature readings measured between the required 105 - 120 degrees Fahrenheit.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2023
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 3
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: DEL SOL HOME (CALIFORNIA)
FACILITY NUMBER: 198602156
VISIT DATE: 04/18/2023
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Operational Requirements:
· The Program Design was reviewed.

· Fire clearance was approved by LA County Fire Department for four (4) non-ambulatory clients.


· Care and supervision to meet the clients needs was observed. G-Tube and Fecal Impaction use was included in the clients restrictive health care plan.
Staffing:

· A total of nine (9) staff members provide care and supervision to the clients including 2 LVNs and 7 DSPs.

Personnel Records/Staff Training:

· Administrator certificate expires 03/26/2024.


· Five (5) staff files were reviewed for criminal background clearance and training.
· Personnel records have health/TB screenings, CPI training, certifications, and 1st Aid/CPR training.
Client Rights/Information:

· Physician orders were reviewed in client files.

Client Records/Incident Reports:

· Five (5) client files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, IPP reports, personal rights, medical consent, nutritional assessments, medication records, and P & I money were reviewed.


Food Service:

· The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.


· Restricted Health Care plan explains the clients need for a modified diet of Jevity and Isosource formula.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: DEL SOL HOME (CALIFORNIA)
FACILITY NUMBER: 198602156
VISIT DATE: 04/18/2023
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Health Related Services:

· Clients are assisted with self-administration of prescription and non-prescription medications.

· Five (5) centrally stored resident medication records were reviewed. Centrally stored medications are kept in a safe and locked place not accessible to clients in care. Medications are given according to Physician directions.


Incident Medical and Dental:

· All clients have a Needs and Services Plan, and COVID-19 vaccination cards on file.

· Staff training was on file.

Disaster Preparedness, and Emergency Intervention:

· A posted Emergency Disaster Plan LIC610D containing emergency evacuation information was observed.

· An emergency drill was conducted on 03/21/2023.



Emergency Intervention:

· No manual restraints or seclusion are used with clients in care.



Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023
LIC809 (FAS) - (06/04)
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