198602556-12-23-2024-28-AS-DKOI-DC8SU4-20241223131031

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602556
Report Date: 12/23/2024
Date Signed: 12/23/2024 01:10:43 PM

Document Has Been Signed on 12/23/2024 01:10 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:	PDM-HORST		FACILITY NUMBER:	198602556
ADMINISTRATOR/ DIRECTOR:	LOPEZ, ARCHIMEDES C		FACILITY TYPE:	735
ADDRESS:	18318 HORST AVE		TELEPHONE:	(562) 552-5579
CITY:	ARTESIA	STATE: CA	ZIP CODE:	90701
CAPACITY: 4		CENSUS: 3	DATE:	12/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:10 AM
MET WITH:	Archimedes Lopez, Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:20 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 Analyst (LPA) Daniel Konishi conducted an unannounced visit at the facility for the purpose of conducting the required annual inspection. LPA utilized the Compliance and Regulatory Enforcement (CARE) Tool to evaluate the facility. LPA Konishi met with Administrator Archimedes Lopez and explained the purpose for the visit. The facility is 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 (3) clients in placement, there are no clients who have a restricted health care condition. All clients residing at this facility receive case management services provided by Harbor Regional Regional Center and East Los Angeles 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 Services, Disaster Preparedness, and Emergency Intervention. During the visit LPA observed the following: Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has sufficient PPE supplies, has an Infection Control Plan. Facility has COVID-19 signage posted throughout the facility. Bathrooms have hand washing signs, soap, and paper towels. Facility Administrator is adhering to infection control requirements.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 12/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024

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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Document Has Been Signed on 12/23/2024 01:10 PM - It Cannot Be Edited

Created By: Daniel Konishi On 12/23/2024 at 12:50 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: PDM-HORST	FACILITY NUMBER: 198602556
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/23/2024

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: 01/13/2025
	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: 12/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024

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: PDM-HORST	FACILITY NUMBER: 198602556
	VISIT DATE: 12/23/2024

NARRATIVE

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Operational Requirements: Emergency Fire Drill was conducted on 12/03/2024. Emergency Disaster/ Earthquake Drills was conducted on 12/03/2024. Facility Administrator is adhering to operational requirements.

Physical Plant & Environment Safety: The facility is a single-story home located in a residential neighborhood and consists of: Four (4) client bedrooms, 2 bathrooms (1 bathroom is for staff), living room, kitchen, activity area, medication, dining area, and garage. All client rooms were inspected and LPA observed client beds and the bedding for each bed were in good condition, adequate lighting provided, storage for client personal belongings was observed for each client. Each client bedrooms include all required furniture: a bed, chair, lamps, and dressers.. The client’s bathroom is clean, sanitary and in a good working condition. Walls and floors were in good repair. Clean towels are kept in the hallway closet and new bed linens are currently in an unoccupied client bedroom’s closet. Toilets and water faucets worked properly. Showers were free of mold/mildew, had adequate lighting, and there are sufficient toiletries that are accessible to clients. Grab bars observed in the bathroom. Bathroom hot water temperature was tested at 112.2 degrees F which is within the required 105-120 degrees F. Facility temperature was comfortable and cool. LPA observed the facility to be clean and appropriately furnished with clear passageways inside and outside. All the sharp knives are locked in the kitchen drawers and inaccessible to clients. Cleaning supplies are locked underneath the kitchen sink and inaccessible to clients. Carbon monoxide detectors were tested and in working condition. Fire extinguishers are in the kitchen and in the garage and both are fully charged and last inspected on 02/08/2024. Backyard area is properly shaded and provide enough space for activities.

Staffing: There is sufficient staffing at the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator, and Staff #1 (S1) to Staff #3 (S3). Staff have current CPR/first aid training and sufficient on-going training that meets the annual requirement. Staff have their Health Screening and Tuberculosis Screening, Employee Rights, Personnel Record on file. Administrator Certificate effective on 06/03/2025. However, based on record review, Administrator does not have required AIDS/HIV & TB training on file.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 12/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024

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: PDM-HORST	FACILITY NUMBER: 198602556
	VISIT DATE: 12/23/2024

NARRATIVE

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Client Rights-Information: Facility does not have any clients requiring postural supports. Client personal rights and House Rules are posted. Per Facility Administrator, facility provides wi-fi services to all clients.

Client Records-Incident Reports: LPA reviewed Client files for Client #1 (C1) through Client #3 (C3). Client files are maintained at the facility and have the following documents in their files - Admission Agreements, Face sheet, Physician's Report (including T.B and Ambulatory Status), Weight log, Client Medication Destruction Record, Appraisal Needs and Services Plan, Individualized Program Plan (IPP), Functional Capabilities Assessment, Client Personal Property, Client Cash Resources, and Clients Personal Rights.

Food Service: The facility has sufficient food supplies of 2-day perishable and a week of non-perishable items. The food is properly stored in the refrigerator (clean and well-maintained). There are no clients with special diets residing at this facility. Kitchen is kept clean. LPA observed the Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.

Health Related Services The medications are centrally stored and in their original containers. LPA reviewed medication for C1 through C3. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubble packed and delivered monthly. First aid kit was observed and has all required items.

Incidental Medical Services: Based on record review and staff interview, there are clients under restricted health conditions and proper staff training for restricted health conditions are in file.

Disaster Preparedness: The facility has an Emergency Disaster Plan readily accessible.

Emergency Intervention: The facility does not use any restraint on clients.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809-D. Exit Interview conducted and a copy of the report with appeal rights were provided to the Administrator Archimedes Lopez.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 12/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024

LIC809 (FAS) - (06/04)

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