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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602208
Report Date: 06/29/2022
Date Signed: 06/29/2022 03:03:43 PM

Document Has Been Signed on 06/29/2022 03:03 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ELEANOR RICHARDSON HOMEFACILITY NUMBER:
198602208
ADMINISTRATOR:HOLLAND, TRAVISFACILITY TYPE:
735
ADDRESS:462 E GROVE STTELEPHONE:
(909) 398-4488
CITY:POMONASTATE: CAZIP CODE:
91768
CAPACITY: 3CENSUS: 3DATE:
06/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:57 PM
MET WITH:Assistant Administrator, Jose AldereteTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vasallo conducted an annual required visit. LPA met with Assistant Administrator, Jose Alderete and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the physical plant, COVID-19 procedures, reviewed clients' medications and records, staff records and observed the food supply. The facility cares for adults with intellectual disabilities and is vendorized by San Gabriel/Pomona Regional Center as a Level 4 Specialized facility.

All client bedrooms were toured. All bedrooms are private rooms and have the required bed, bedframe, linen, dresser, light, and closet space. Both client bathrooms were toured and the hot water was 111.3 degrees which is within the required 105 - 120 degrees. There were no toxic chemicals accessible to clients. All chemicals are locked in a cabinet in the garage. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and are operating properly. The common areas include the living room and dining area. These areas are clean and have the required furniture. Facility currently has at least a 30-day supply of PPEs stored in the staff office. There are no cameras inside or outside the facility. There is a screening station at the entrance of the facility, however LPA was not screened at the time of entry. Client's visitor was also observed entering the facility and was not screened at the time of entry. Staff do document client temperatures and symptoms daily as required.

Client files were reviewed to confirm emergency contacts and individual program plans are updated. Staff files were reviewed to confirm health screenings, training and fingerprint clearances. All clients' medications were reviewed. Medications are documented properly and given as prescribed.

Per California Code of Regulations, Title 22, the deficiencies observed during the visit are attached on the 809D. Exit interview held. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Tony Vasallo
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2022
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 06/29/2022 03:03 PM - It Cannot Be Edited


Created By: Tony Vasallo On 06/29/2022 at 02:53 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: ELEANOR RICHARDSON HOME
FACILITY NUMBER: 198602208

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80072(a)(2)
Personal Rights
(a) Each client shall have personal rights including: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. Infection Control Practices - Type B: 80072(a)(2) - Routine symptom screening (+/- temperature and symptom check) has been initiated at entry for all staff, residents, and visitors. Facility did not screen LPA at the time of entry nor the client's family when they came to visit.
POC Due Date: 07/08/2022
Plan of Correction
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Facility will submit proof of training for staff regarding routine symptom screening for visitors.
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:Wei Siew Ho
LICENSING EVALUATOR NAME:Tony Vasallo
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2022


LIC809 (FAS) - (06/04)
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