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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602599
Report Date: 08/22/2024
Date Signed: 08/22/2024 01:40:17 PM

Document Has Been Signed on 08/22/2024 01:40 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:DEL SOL HOME (BEVERLY)FACILITY NUMBER:
198602599
ADMINISTRATOR/
DIRECTOR:		GONZALES, HEINRICHFACILITY TYPE:
735
ADDRESS:9914 BEVERLY STTELEPHONE:
(562) 243-4234
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 4CENSUS: 4DATE:
08/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Mark De Ocampo - AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:53 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Mark De Ocampo (administrator) and explained the purpose for today’s visit. The facility is licensed to serve 4 Non-Ambulatory Clients ages 18-59 years. The facility currently has 4 clients serviced through Harbor Regional Center.

The facility is a single-story home located in a residential area in Bellflower, Ca. A tour of the facility includes: living room, kitchen, 4 bedrooms, 2 bathrooms, detached garage for storage with full bath (there is live in staff unit behind garage), front yard and back yard.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:


Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility.
Physical Plant & Environment Safety: LPA toured facility, clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested in the client bathrooms and was within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items have a secure location, however, during tour LPA observed cleaning supplies stored in an unlocked cabinet both on back porch and in client bathroom (large bath with storage cabinet), LPA also observed kitchen knives to ve in an unlocked kitchen drawer, details will be cited on the 809-D. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged.
(Continued on LIC809-C)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2024
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 08/22/2024 01:40 PM - It Cannot Be Edited


Created By: Tena Herrera On 08/22/2024 at 12:43 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: DEL SOL HOME (BEVERLY)
FACILITY NUMBER: 198602599

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(A)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (A) There is written direction from a physician, on a prescription blank, specifying the name of the client, the name of the medication, all of the information specified in Section 80075(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication of when the physician should be contacted for a medication reevaluation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as during medication review LPA observed Client #1 to have Phillips' (saline Laxative) milk of magnesia (1200mg per 15mL) stored with clients medication, Administrator Mark could not provided proof that medication was prescribed by physician to client and confirmed that medication has been given to client, Also LPA found (for Client #1) medication in a sandwich bag labeled with sharpie Risperidone (1/2-1mg 1-2mg) medication was not in orginal container and in baggie (LPA asked administrator about this medication and he stated that medication is meant for disposal), this poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2024
Plan of Correction
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*during visit LPA advised Administrator Mark to discontinue use until physician gives an order for medication, Admin confirmed will not administer medication and placed seperate from all other daily meds*
*LPA advised Admin that expired medication/medication meant for disposal should NOT be stored in same container as their daily medications to avoid confusion when administering medication, Administrator removed medication and stored seperate from daily medication*
Licensee/Administrator to conduct a staff training on the above regualtion and provide a copy of training materials and training participant log to be emailed to LPA by 8/29/24 tena.herrera@dss.ca.gov.

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:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/22/2024 01:40 PM - It Cannot Be Edited


Created By: Tena Herrera On 08/22/2024 at 01:04 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: DEL SOL HOME (BEVERLY)
FACILITY NUMBER: 198602599

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)(1)

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as during tour LPA observed 2 knives stored in an unlocked drawer in the kitchen, this poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2024
Plan of Correction
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*during visit staff removed fabuloso gallon and stored in locked storage cabinet in garage and locked the cabinet in bathroom*
*staff removed knives and placed in a locked metal box with other sharps during visit*
Licensee/Administrator to conduct a staff training in proper storage of disinfectants, cleaning solutions, poisons, firearms and other dangerous weapons that could pose a danger if readily available to clients, a copy of training materials and training participant log to be emailed to LPA by 8/29/24 tena.herrera@dss.ca.gov.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2024


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: DEL SOL HOME (BEVERLY)
FACILITY NUMBER: 198602599
VISIT DATE: 08/22/2024
NARRATIVE
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Operational Requirements: Staff have proper training to meet the needs of the clients in care. Facility has an activity area furnished for outdoor use. Last fire/earthquake drill was conducted on 8/1/24.
Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the clients in the case of an emergency.
Personnel Records-Training: Staff files are maintained in a secure location. LPA reviewed 5 staff files during today’s visit, files reviewed contained the following: Criminal Background Clearance, First-Aid/CPR/AED and sufficient on-going training. Merci Cania Gonzales maintains a valid certificate that expired on 3/26/2024, however, proof that they filed for renewal on 1/29/24 was provided.
Client Rights-Information: Facility provides telephone landline and internet for the clients. Client rights posters and reporting posters are displayed within the facility.
Client Records-Incident Reports: Client files are maintained in a secured locked cabinet and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. LPA reviewed 4 client files with no issues.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Service: Staff designated to administer medication have the proper annual training on file. Medications are centrally stored in a locked cabinet, however during visit LPA observed Client #1 to have 1 medication stored with daily medication that was not labeled or on the physician's medication list for client, also LPA found (for Client #1) medication in a sandwich bag labeled with sharpie, medication was not in original container and in baggie, details will be documented on 809-D.
Incidental Medical & Dental: All training is documented in the facility personnel files. Staff performance is reviewed annually, and documentation is maintained in the personnel files.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Facility maintains documentation of the required emergency drills.
Emergency Intervention: Clients at this facility do not need the use of restraints or de-escalation techniques.
Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during todays visit will be documented on the 809D.
Exit interview was held and a copy of the report and appeal rights will be emailed to Merci, Mark and Jorgelle.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC809 (FAS) - (06/04)
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