198602255-4-12-2022-11-AS-EDAT-CDEJ3Y-20220412064219

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602255
Report Date: 04/11/2022
Date Signed: 04/12/2022 06:43:21 AM

Document Has Been Signed on 04/12/2022 06:43 AM - 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 DR #100
MONTERY PARK, CA 91754

FACILITY NAME:	CALIFORNIA MENTOR - DOMINGUEZ HOME		FACILITY NUMBER:	198602255
ADMINISTRATOR:	ROSAS, CLAUDIO		FACILITY TYPE:	735
ADDRESS:	214 E DOMINGUEZ		TELEPHONE:	(909) 483-2505
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY: 3		CENSUS: 2	DATE:	04/11/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:03 AM
MET WITH:	Claudio Rosas		TIME COMPLETED:	12:12 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 04/11/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with Program Director Claudio Rosas. LPA explained the purpose of today’s visit. The facility is licensed to operate for three (3) non-ambulatory ages 18 through 59. The clients are Harbor Regional Center consumers. The facility is a single-story structure located in a residential neighborhood. It consists of the following: three (3) client's rooms, two (2) common bathrooms, a living area, dining area, kitchen, and outside patio area. LPA toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. A comfortable temperature of 73 degrees was maintained in the facility. LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, and toxins are not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. Fire extinguishers were charged, and smoke detectors and carbon monoxide were operable. A review of Medication Records Administration (MAR) and Fire Drills were observed to be maintained in order and accurate. The last fire drill was conducted on 03/24/22. Landline telephones were in working condition. Evaluation Report Continues on LIC 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: CALIFORNIA MENTOR - DOMINGUEZ HOME	FACILITY NUMBER: 198602255
	VISIT DATE: 04/11/2022

NARRATIVE

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DEFICIENCY:
LPA observed at 11:07 am both restrooms' faucets used by clients for personal care such as shaving and grooming delivered hot water at 128.9 degrees F. Hot water temperature controls were not maintained to automatically regulate the temperature of hot water delivered to plumbing fixtures used by clients 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).

INFECTION CONTROL:
LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff and resident vaccination records was performed.

Deficiency cited on LIC 809D.

An exit interview and a copy of this report were provided to Claudio Rosas.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/12/2022 06:43 AM - It Cannot Be Edited

Created By: Ernand Dabuet On 04/11/2022 at 12:11 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 DR #100
MONTERY PARK, CA 91754

FACILITY NAME: CALIFORNIA MENTOR - DOMINGUEZ HOME	FACILITY NUMBER: 198602255
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80088(e)(2)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (2) Taps delivering water at 125 degrees F (51.6 degrees C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) the licensee did not comply with the section cited above in [2] out of (2) count] [(bathrooms faucets) had a hot water temperature of 128.9 which poses immediate health, and safety, or personal rights risk to persons in care.
	POC Due Date: 04/12/2022
	Plan of Correction
1 2 3 4	The licensee will adhere to Title 22 regulations 80088(e)(2) and ensure the water temperature will meet Title 22 regulations between 105 degrees to 120 degrees F. The licensee will adjust the water heater to comply.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Eva M Alvarez

LICENSING EVALUATOR NAME:

Ernand Dabuet

LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022

LIC809 (FAS) - (06/04)

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