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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602556
Report Date: 02/16/2023
Date Signed: 02/16/2023 03:42:15 PM

Document Has Been Signed on 02/16/2023 03:42 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PDM-HORSTFACILITY NUMBER:
198602556
ADMINISTRATOR:LOPEZ, ARCHIMEDES CFACILITY TYPE:
735
ADDRESS:18318 HORST AVETELEPHONE:
(562) 552-5579
CITY:ARTESIASTATE: CAZIP CODE:
90701
CAPACITY: 4CENSUS: 1DATE:
02/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Administrator- Archimedes LopezTIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Ashley Calderon and Erik Zaragoza visited the above facility as an unannounced Required Annual 1-Year Inspection. Upon arrival LPAs met caregiver Miguel Mamuzon and discussed the purpose for the visit. Shortly after LPAs met with Administrator Archimedes "Archi" Lopez.

PDM-Horst is an adult residential facility licensed to serve a total of four (4) non-ambulatory developmentally disabled adults between the ages of 18-59, one (1) can be bedridden. This facility is approved for one (1) hospice waiver. Currently there are three non-ambulatory clients, no bedridden and no hospice clients. Clients placement agencies are East L.A Regional Center and Harbor Regional Center.

PDM-Horst is a single story facility containing: all living room, kitchen, dining room, four bedrooms, two in a half bathrooms, laundry area in attached garage is inaccessible to clients, and an outside area.

During today's visit the following was observed, reviewed and inspected: LPAs requested client present during visit medication and Medication Administration Record (MAR), all medications have labels and physician's orders, all medication were noted on the MAR, no deficiencies noted. LPA reviewed two client files, all documentation required was reviewed. LPAs observed First Aid and Manual and observed Medication kept locked. LPAs and "Archi" inspected the physical plant: Kitchen: contained refrigerator, freezer, microwave and counter tops were clean and operable, sufficient supply of perishable and nonperishable foods, all sharp objects are locked, medications and staff/client records were locked and inaccessible to clients in care.

Bedrooms: all bedrooms contain the required furniture, lighting fixtures, mattresses, and box springs are in good repair, beds contain the required amount of linen.
(Continuation on LIC809C...)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/16/2023
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PDM-HORST
FACILITY NUMBER: 198602556
VISIT DATE: 02/16/2023
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Hallways: all hallways are free of obstructions, walls, ceiling and floor are if good repair, smoke detectors tested and functioning (hardwired), carbon monoxide detector functioning. Night lights observed.

Bathrooms: shower, toilets and face bowls operational, nonskid mates and grab bars observed,.

Garage: organized, used for storage, contains PPE, Emergency Items, food and water, inaccessible to clients.

Other:
All of the required documents are posted in a clearly visible areas, hygiene products observed, all of the exits are marked, all windows have screens in good repair.

Yards: front and back yards are well maintained and free of debris, shaded area observed.

Fire Drills are conducted quarterly last fire drill was conducted Jan 2022, two fire extinguishers are fully charged. Administrator Certificate expires 06/03/2023, Licensing Fees are current. LPA used the Inspection Tool.

No Deficiencies cited under California Code of Regulations Title 22

Exit Interview Conducted and a copy of this was provided.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
LIC809 (FAS) - (06/04)
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