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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602383
Report Date: 03/10/2023
Date Signed: 03/10/2023 04:38:10 PM

Document Has Been Signed on 03/10/2023 04:38 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:RACHEL'S QUALITY HOMEFACILITY NUMBER:
198602383
ADMINISTRATOR:SABILLO, VENERANDA OFACILITY TYPE:
735
ADDRESS:18202 GALATINA STREETTELEPHONE:
(626) 295-2976
CITY:ROWLAND HEIGHTSSTATE: CAZIP CODE:
91748
CAPACITY: 4CENSUS: 3DATE:
03/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Rachel Saeillo TIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Christine Wong and Erik Zaragoza conducted the unannounced Annual Inspection and met with DSP Roselyn Ochoada who allowed the entry of the facility. Shortly after, the facility manager Rachel Saeillo arrived and explained the reason of today's visit and will be using the Compliance And Regulatory Enforcement (CARE) Tools to inspect the facility. The facility is licensed for age range 18 through 59.5 and ambulatory only.

The following domains were reviewed during today's annual required visit which included: infection control, physical plant and environmental, operational requirements, staffing, personnel records-training, client rights- information, client records-incident reports, food service, health related services, incidental medical services, disaster preparedness and emergency intervention.

Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting once a day and more often for high touched surfaces. Facility has sufficient PPE supplies and has an Infection Control Plan.
Physical Plant and Environmental: The facility is a single story house and located in a cul de sac around the residential neighborhood area. The home includes: living room/common area, dining area, kitchen/laundry area, three (3) clients bedrooms, two (2) clients bathrooms and staff office. Facility has an operable smoke detector in each room and a carbon monoxide detector located near clients rooms. Knives, cleaning solutions, and disinfectants are locked, making them inaccessible to clients. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F.

(See LIC809C for continuation)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2023
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 4
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: RACHEL'S QUALITY HOME
FACILITY NUMBER: 198602383
VISIT DATE: 03/10/2023
NARRATIVE
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Operational Requirements: The fire clearance was approved for four (4) ambulatory. The facility will assist with client needs according to IPP and they would provide care and supervision to clients too. Clients also have their right to attend activity in the community.
Staffing: There's sufficient staffing in the facility. The administrator (Veneranda Sabillo) certificate will be expired on 09/17/2024. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. The night staff did not have any training about facility planned emergency procedures.
Personnel Records-Training: Staff files are maintained at the facility. The administrator did not have the HIV and TB training in the file and last one was dated on 2018. The facility manager also did not have the current first aid in file and it was expired on 02/18/2023.
Client RIGHTS INFORMATION: The facility provide internet service and at least internet access device to clients and no client need any postural support.
Client Records-Incident Reports: Client files are maintained at the facility and have the following documents in their files - Admission Agreements, IPP, updated physician report and functional capabilities assessment.
Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The food are properly stored in the refrigerator.
Health Related Services: The medication is centrally stored and locked in the kitchen cabinet and inaccessible to clients. All the clients medication are given according the physician direction. The last staff medication management training was in June, 2022.
Incidental Medical Services: No client in the facility has any restricted health condition or prohibited health condition.
Disaster Preparedness: The facility has an updated Emergency Disaster Plan posted with contact numbers with relocation sites.
Emergency Intervention: It's not applicable for the facility

During the annual inspection, LPAs interviewed 2 staff and 1 client due to only one client available in the facility at that time..

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 1

Exit interview was conducted, Appeals Rights discussed and a copy of the report was given to the facility manager.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/10/2023 04:38 PM - It Cannot Be Edited


Created By: Christine Wong On 03/10/2023 at 01:40 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: RACHEL'S QUALITY HOME
FACILITY NUMBER: 198602383

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85065.6(b)(1)
Night Supervision
(b) Employees providing night supervision from 10:00 p.m. to 7:00 a.m., as specified in (c) through (f) below, shall be available to assist in the care and supervision of clients in the event of an emergency, and shall have received training in the following: (1) The facility's planned emergency procedures.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPAs reviewed the two night staff do not have the training fro facility planned emergency procedures which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/24/2023
Plan of Correction
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The administrator will ensure the night staff should receive training for facility planned emergency procedures and administrator will send the training log for POC due date.
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
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Based on record review, the administrator did not have an updated HIV and TB training in file and last one was dated in 2018 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2023
Plan of Correction
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The administrator will ensure to have the HIV and TB training every two years and will send the updated HIV and TB training documents to LPA by POC due date.
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:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/10/2023 04:38 PM - It Cannot Be Edited


Created By: Christine Wong On 03/10/2023 at 01:40 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: RACHEL'S QUALITY HOME
FACILITY NUMBER: 198602383

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA observed the facility manager first aid certfiicate was expired on 02/18/23 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2023
Plan of Correction
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The administrator will ensure staff receive training in first aid and the administrator send the faciltiy manager updated first aid certificate to LPA by POC due date.
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:David Sicairos
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2023


LIC809 (FAS) - (06/04)
Page: 4 of 4