198602364-8-2-2024-28-AS-DKOI-D7RU8J-20240802152136

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602364
Report Date: 08/02/2024
Date Signed: 08/02/2024 03:22:39 PM

Document Has Been Signed on 08/02/2024 03:22 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:	CN HOME 2		FACILITY NUMBER:	198602364
ADMINISTRATOR/ DIRECTOR:	MATHARU, ANITA		FACILITY TYPE:	735
ADDRESS:	14516 PIONEER BLVD		TELEPHONE:	(310) 612-0978
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY: 4		CENSUS: 4	DATE:	08/02/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:15 AM
MET WITH:	MelindaN Acosta-Black, Staff		TIME VISIT/ INSPECTION COMPLETED:	03:40 PM

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Licensing Program Analysts (LPA) Daniel Konishi conducted an unannounced Annual Required Visit on 08/02/2024. LPA was met by Reina Barrera and explained the purpose of the visit. Reina Barrera assisted in tour of facility. Administrator was notified over the phone of the visit but could not assist with the visit as they are currently on leave. Melinda Acosta-Black, Staff arrived shortly after to the facility and assisted with the visit. The facility has a fire clearance approved for six (6) non-ambulatory clients. All clients receive services from Harbor Regional Center. LPA requested and obtained a copy of Personnel Report, and Resident Roster.

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. LPA observed that the facility has infection control plan in place.

Physical Plant/Environment Safety:

· LPA conducted the tour assisted by Reina Barrera and observed the following:

The facility is a single-story building in a residential area, with a kitchen, dining room, living room, 4 client bedrooms, 1 live in staff office, 2 bathrooms, backyard with shaded area and a detached garage.
· All passageways, walkways, driveway, steps and patio are free from obstructions. The front, back and side areas of the house are free of hazards.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024

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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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: CN HOME 2	FACILITY NUMBER: 198602364
	VISIT DATE: 08/02/2024

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· Hallway linen closet: Contained plenty of linens and towels.

· Beds have the required furniture including bedframes, dressers, lamps, nightstand and chairs. Beds have the required linens and the linens are in good condition.

· Fire extinguisher was observed on hallway last reviewed 03/01/2024.

· Carbon monoxide detectors are tested and in working condition.
· Cleaning supplies are kept locked under kitchen sink away from food supplies.
· Sharps are kept locked in the kitchen drawer.
· Shared client bathrooms were observed to be clean and contained soap and paper towels.
· Shower and toilet had grab bars. Toilet was in working condition.
· Water temperature in this bathroom#1 was measured at 111.5 degrees F and Bathroom #2 was measured at 111.9 degrees F which is in the required 105 – 120 degrees5 F per Title 22 Regulations.

Operational Requirements:
· The facility is licensed to serve (6) six non-ambulatory developmentally disabled adults ages 18 thru 59 years old..
Staffing:
· A total of five (5) full-time staff members provide care and supervision to the clients.

Personnel Records / Staff Training:

· Administrator’s certificate effective to 08/28/2025.

· Administrator does not have required HIV/ & TB training in file which does not meet Title 22 Regulations.
· Four (4) staff files were reviewed for criminal background clearance and training.
· Personnel records have health/Tuberculosis (TB) screenings, certifications, and 1st Aid/CPR training.
· Facility has per regulation staff training in file.

Client Rights/Information:

· Physician orders were reviewed in client files.
· Internet access and telephone are provided for client’s use.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024

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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CN HOME 2	FACILITY NUMBER: 198602364
	VISIT DATE: 08/02/2024

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Client Records/Incident Reports:
· Four (4) client files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, TB clearance, Individual Program Plan, Appraisal/Needs and Services Plan, personal rights, medication records, and Personal and Incidental (P & I) money were reviewed.

Food Services:

· 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 is in file for the clients in the facility.
Health Related Services:
· Clients are assisted with self-administration of prescription and non-prescription medications.

· Four (4) centrally stored resident medication records locked in a cabinet in the staff office room were reviewed.

· First Aid Kit was reviewed and has required items.
· LPA reviewed four (4) out of four (4) client medications and Medication Administration Record (MAR).
Incidental Medical and Dental:
· All clients have a Needs and Services Plan, and COVID-19 vaccination cards on file.

· The facility has clients under restricted health conditions and does has an updated restricted health care plans in file. .

Disaster Preparedness, and Emergency Intervention:

· A posted Emergency Disaster Plan LIC 610D containing emergency evacuation information was observed. · An emergency drill was last documented on 07/20/2024.

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, the deficiencies observed during the visit are documented on the LIC809Ds. Exit interview held and a copy of the report along with appeal rights were provided.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/02/2024 03:22 PM - It Cannot Be Edited

Created By: Daniel Konishi On 08/02/2024 at 03:09 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: CN HOME 2	FACILITY NUMBER: 198602364
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85064(k)

Administrator Qualifications and Duties

(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, Administrator's file is missing training on HIV and TB which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/16/2024
	Plan of Correction
1 2 3 4	Administrator will send a copy of the HIV and TB training certificate to the LPA by the POC due date.

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:

David Sicairos

LICENSING EVALUATOR NAME:

Daniel Konishi

LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024

LIC809 (FAS) - (06/04)

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