198602546-8-3-2023-28-AS-EZAA-CUCRVX-20230803132217

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602546
Report Date: 08/03/2023
Date Signed: 08/03/2023 01:22:44 PM

Document Has Been Signed on 08/03/2023 01:22 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	HOLY HILL INC-BENFIELD HOME		FACILITY NUMBER:	198602546
ADMINISTRATOR:	SANTOS, MARIA TERESA F		FACILITY TYPE:	735
ADDRESS:	14732 BENFIELD AVE		TELEPHONE:	(562) 506-5010
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY: 4		CENSUS: 3	DATE:	08/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:48 AM
MET WITH:	Edward Francisco - Owner		TIME COMPLETED:	01:40 PM

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Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to Ed Francisco who is the owner of the facility and was granted access into the facility. Administrator Ronald Dino arrived shortly thereafter. There are one (1) ambulatory and two (2) non-ambulatory developmentally disabled clients who reside in the home. The facility is vendored through Harbor Regional Center.

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 asked administrator to send a completed infection control plan to LPA within 7 days.

Physical Plant/Environment Safety:

· The facility is a single-story home located in a residential neighborhood that is licensed for a capacity of three (3) non-ambulatory developmentally disabled clients between the ages of 18-59, and one (1) hospice waiver. It consists of three (3) individual client bedrooms, a living room, dining room, a kitchen which also functions as an office, one (1) shared client bathrooms (R1) which had a hot water temperature measured at 105.8 Degrees F, and a second private restroom (R2) which measured at 105.6 Degrees F, a front and back patio area which contains the facility’s washing and drying machines, and a detached garage which serves as a storage area for the facility.

· The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Fire alarm system is operational.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023

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: HOLY HILL INC-BENFIELD HOME	FACILITY NUMBER: 198602546
	VISIT DATE: 08/03/2023

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The facility has two (2) fully charged fire extinguishers that are kept in the kitchen of the facility as well as in the laundry area in the backyard of the facility. Cleaning supplies and toxic substances are inaccessible to clients in the backyard of the facility..
· Water temperature readings measured between the required 105 - 120 degrees Fahrenheit.
Operational Requirements:
· The Program Design was reviewed.

· Fire clearance was approved by LA County Fire Department for three (3) non-ambulatory clients.

· Care and supervision to meet the clients’ needs was observed.
Staffing:

· A total of seven (7) full-time staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

· Administrator’s certificate is active and effective through 12/17/2023.

· Five (5) staff files were reviewed for criminal background clearance and training.
· Personnel records have health/TB screenings, CPI training, certifications, and 1st Aid/CPR training.
Client Rights/Information:

· Physician orders were reviewed in client files.

Client Records/Incident Reports:

· Three (3) client files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, nutritional assessments, medication records, and P & I money were reviewed.

Food Service:

· 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.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023

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: HOLY HILL INC-BENFIELD HOME	FACILITY NUMBER: 198602546
	VISIT DATE: 08/03/2023

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· No restricted Health Care plan required for the clients in the facility.

Health Related Services:

· Clients are assisted with self-administration of prescription and non-prescription medications.

· Three (3) centrally stored resident medication records were reviewed. Centrally stored medications are kept in a safe and locked place not accessible to clients in care. Medications are given according to Physician directions.

Incident Medical and Dental:

· All clients have a Needs and Services Plan, and COVID-19 vaccination cards on file.

· Staff training was on 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 7/24/2023.

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 deficiency observed during the visit are documented on the LIC809D. Exit interview held and a copy of the report along with appeal rights were provided.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023

LIC809 (FAS) - (06/04)

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