198602599-9-20-2023-28-AS-CWOG-CVTQ9W-20230919115901

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602599
Report Date: 09/19/2023
Date Signed: 09/20/2023 07:59:34 AM

Document Has Been Signed on 09/20/2023 07:59 AM - 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:	DEL SOL HOME (BEVERLY)		FACILITY NUMBER:	198602599
ADMINISTRATOR:	GONZALES, HEINRICH		FACILITY TYPE:	735
ADDRESS:	9914 BEVERLY ST		TELEPHONE:	(562) 243-4234
CITY:	BELLFLOWER	STATE: CA	ZIP CODE:	90706
CAPACITY: 4		CENSUS: 4	DATE:	09/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Mark De Ocampo		TIME COMPLETED:	12:15 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)Christine Wong conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with staff Ynez Mercado and explained the reason of the visit. Shortly after, the assistant administrator Mark De Ocampo and Jorgellean Catuano arrived and assisted with the visit. The facility is approved to serve developmentally disabled for age range 18 though 59. 4 non-ambulatory. The facility is licensed as a Level 4I Specialized home vendored by Harbor Regional Center. The following twelve (12) tool domains were observed and reviewed: Infection Control, Physical Plant/Environmental Safety, Operational Requirements, Staffing, Personal 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: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility still encourages hand washing, visitor screening and wearing mask. The facility has an Infection Control Plan and COVID-19 mitigation plan in place. 2. Physical Plant and Environmental Safety: The facility is a single story house and located in a residential neighborhood area. The facility includes four clients bedrooms, two clients bathrooms, living room, dining area, kitchen and detached garage. Each client bedroom has one bed (half rail bed), one chair, night stand, required furniture and beddings and sufficient lighting and closet space. The two clients bathrooms are clean, sanitary and in a working condition. Bathroom#2 is accommodated for wheelchair clients. The hot water in two client bathrooms were tested between 116.6 and 117.3 degrees F which are within the Title 22 regulation. All the appliances in the living room and kitchen are working properly. The sharp knives are locked in the lock box in the kitchen cabinet. The cleaning supplies and chemicals are locked in the cabinet in the bathroom#2. (See LIC809 for continuation)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

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: DEL SOL HOME (BEVERLY)	FACILITY NUMBER: 198602599
	VISIT DATE: 09/19/2023

NARRATIVE

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LPA inspected the smoke detectors and carbon monoxide detectors are interconnected and they are all working well. The extra linen are located in the hallway cabinet. The extra personal hygiene products are located in the cabinet in the bathroom#2.The hallway light will always on during night time. The facility has a land line telephone system. The passageway, walkway and patio are free of obstruction.

3. Operational Requirements: The facility is licensed for 4 non-ambulatory clients and currently all the clients are non-ambulatory. The last fire drill was conducted on 09/01/23. The clients would attend the community activities if there's an opportunity or chance. The facility has a shaded area with table and chairs for client to utilize the outdoor activities.

4. Staffing: The facility has sufficient staffing in the facility. The staff who works at the night shift did have the facility planned emergency procedure training.

5. Personnel Records-Training: The staff files are stored in a locked file cabinet near the staff desk. LPA inspected all staff files, all staff are over 18 years old, associated with the facility and fingerprint cleared. All staff files also include: health screening, TB test result and required training hours and updated first aid certificate. The current administrator is Merci Gonzales and administrator certificate expiration date on 03/26/2024 and she has the updated HIV and TB training certificate.

6. Client's Right: Currently the facility has no client required postural support. The facility does provide at least one internet access device such as computer, smart phone or tablet for client's day program or communicating with clients' families.

7. Clients Records-Incident Reports: The client files are stored in the closet next to the staff desk. LPA inspected all four (4) clients files and they all have the required documents which included face sheet, admission agreement, functional capability assessment, physician report, TB test , ambulatory status, medication list and Individual Program Plan (IPP).

8. Food Service: The facility has a food supply for two days perishable and seven days non-perishable, Currently two clients are on puree and liquid diet. Two clients are on G-tube. The food in the facility are stored probably.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

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: DEL SOL HOME (BEVERLY)	FACILITY NUMBER: 198602599
	VISIT DATE: 09/19/2023

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9. Health Related Services: The medications are centrally stored in the medication cabinet near the kitchen area. LPA inspected all four (4) clients' medication and they are seemed updated and accurate.

10.Incidental Medical Services: Currently all four clients are under restricted health care plan. LPA reviewed all four (4) client's files and they all have an updated restricted health condition plan in the client's files signed by the doctor and all staff did receive the training annually.

11. Disaster Preparedness: The facility has an updated emergency disaster plan dated on 10/7/2022 and last fire and emergency/earthquake drill was conducted on 09/01/23. The facility also has two temporary alternative shelter location.

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

No deficiencies observed during the visit.

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

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC809 (FAS) - (06/04)

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