198602383-2-29-2024-28-AS-CWOG-D2WS3S-20240229123136

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602383
Report Date: 02/29/2024
Date Signed: 02/29/2024 12:32:50 PM

Document Has Been Signed on 02/29/2024 12:32 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 HOME		FACILITY NUMBER:	198602383
ADMINISTRATOR:	SABILLO, VENERANDA O		FACILITY TYPE:	735
ADDRESS:	18202 GALATINA STREET		TELEPHONE:	(626) 295-2976
CITY:	ROWLAND HEIGHTS	STATE: CA	ZIP CODE:	91748
CAPACITY: 4		CENSUS: 2	DATE:	02/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Rachel Sabillo		TIME COMPLETED:	12:40 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	Licensing Program Analysts (LPAs) Christine Wong and Daniel Konishi conducted the unannounced Annual Inspection and met with Administrator Rachel Sabillo who allowed the entry of the facility 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 and ambulatory only. The facility is vendorized as Level 4G home with San Gabriel Pomona Regional Center. 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. 1. Infection Control Plan: The facility staff would practice hand washing and using gloves when they have clients in the facility. Staff would clean and disinfect once a day and more often for high touched surfaces area. Facility has sufficient PPE supplies and has an Infection Control Plan in place 2. Physical Plant and Environmental Safety: The facility is a single story house and located in residential neighborhood area. The facility includes: living room, dining area, kitchen, three clients bedrooms, two clients bathrooms and staff office. Bedroom#1 has two beds, two chairs, two night stands, required beddings and furniture and sufficient lighting and closet space. Bedroom#2 and #3 has one bed, one chair, one night stand, one dresser, required furniture and bedding and sufficient lighting and closet space. The two clients bathrooms are clean, sanitary and in a good working condition. The hot water temperature in the client bathrooms are tested at 113 degrees F. which is within the Title 22 regulation. The appliances in the kitchen are working well. The sharp knives were locked in the box in the closet cabinet in the staff office. The cleaning supplies are stored and locked in a cabinet in the staff office. The extra personal hygiene products are stored in a cabinet near the entrance door. LPA inspected the smoke detectors and carbon monoxide detectors are working properly. The hallway night is always on during the night time for client to access the non-private bathrooms. The facility has a telephone service on the premises. The passageway, walkway and patio are free of obstruction.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

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
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: 02/29/2024

NARRATIVE

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3. Operational Requirements: All clients in the facility are ambulatory which is within the fire inspection limit. The facility has a shaded area with table and chairs for client to utilize the outdoor activity. The client is able to attend or participate community activities if there's a chance or as needed.

4, Staffing: The facility has a sufficient staffing in the facility. The NOC shift staff has an updated planned emergency procedure training.

5. Personnel Records-Training: The staff files are stored in the file cabinet in the staff office. LPA inspected three staff files. All staff are over 18 years old and background check cleared and associated with the facility. All the staff files have the required documents included: health screening, TB test result, updated first aid certificate and required training hours. The administrator is Veneranda Sabillo and administrator certificate expiration date on 09/17/2024. The administrator has the updated HIV and TB training certificate.

6. Client's Right: No client in the facility required any postural support at the present time. The facility would provide at least internet access device equipped with video conferencing.

7. Food Service: The facility provide three meals a day for the clients. No client is on any modified diet. The facility has ample supply of two days perishable and seven days non perishable food supply in the facility. All the food are stored properly.

8. Client Records/Incident Reports: The client files are stored in a file cabinet in the staff office. LPA inspected all two clients files and they all have required documents including face sheet, functional capacity assessment, admission agreement, Individual Program Plan (IPP), updated physician report, medication list and ambulatory status.

9. Health Related Services: The medication is centrally stored and locked in the kitchen cabinet. LPA inspected the two clients' medication and they all seemed updated and accurate. All the clients have the 30 days supply of medication in the facility.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

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
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: 02/29/2024

NARRATIVE

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9. Incidental Medical Services: No client in the facility has any restricted health condition plan and they are not accepting any client with prohibited health condition.

10. Disaster preparedness: The facility has an updated emergency disaster plan. The last fire/disaster drill was conducted on October, 2023. The facility has two alternative shelter location.

11. Emergency Intervention: They are not using any restraints in the facility.

No deficiencies were observed during the annual inspection.

Exit Interview conducted. A copy of the report was provided to the administrator

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

LIC809 (FAS) - (06/04)

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