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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602601
Report Date: 12/02/2023
Date Signed: 12/02/2023 01:32:23 PM

Document Has Been Signed on 12/02/2023 01:32 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 (BEACH)FACILITY NUMBER:
198602601
ADMINISTRATOR:GONZALES, MERCI CANIAFACILITY TYPE:
735
ADDRESS:10248 BEACH STTELEPHONE:
(562) 243-4234
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 4CENSUS: 4DATE:
12/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:17 AM
MET WITH:Anna Marie Tomilloso - AdministratorTIME COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required-1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Maybelline Tayag, Direct Support Professional (DSP) and Lawrence Llado, Direct Support Professional (DSP) and explained the purpose of the visit. Administrator Anna Marie Tomilloso arrived at 10:30am and assisted LPA with the inspection. At 11:00am, Merci Gonzales, Licensee also arrived to assist LPA. The facility is licensed to care for (4) Developmentally Disabled Adults, non-ambulatory, ages 18 through 59. All clients residing at this Specialized facility receive case management services provided by Harbor Regional Center.

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

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained. The staff wore masks throughout their shift and disposable gloves are used to clean and disinfect the high touched surfaces in the common areas. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Facility has COVID-19 signage posted at the entrance door. Bathrooms have hand washing signs, soap and paper towels. Staff are adhering to infection control requirements.

Physical Plant/Environment Safety: The facility is a single storey home located in a residential neighborhood, contains a total of (4) resident bedrooms, (2) full bathrooms, a living room/activity area, kitchen, dining area, backyard, and detached garage. Currently, there are four (4) clients living in the facility. The interior and exterior physical plant was inspected. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, chair and sufficient closet space. Bathrooms have non-skid materials and contained hygiene supplies including liquid soap, paper towels, and toilet paper. Exit doors are free of any obstruction and there are no pools or large bodies of water. Backyard was inspected and LPA observed a separate staff room and bathroom outside. LPA also observed miscellaneous items and unused bins all over the side yards. Detached garage was inspected and there is an extra refrigerator/freezer to stock up additional food items. Kitchen knives, sharps objects, cleaning supplies and toxic substances are locked and inaccessible to clients. There is a fire extinguisher observed to be fully charged and was purchased on 01/15/2023. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. At 10:25am, hot water supply measured 109.8 in bathroom #1, and 111.2 in bathroom #2.

Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has not been added to the Plan. A fire clearance for (4) clients is in place. Liability Insurance policy in the amount of $1,000,000.00 each occurrence and $3,000,000.00 in the total annual aggregate is valid and will expire on 03/31/2024. Surety Bond (Summa Insurance Services) is in effect and in force with bond amount of $2000. The insurance will expire on 04/28/2025. Last Fire and Earthquake Drills were conducted on 11/01/2023 and drills with staff and clients are conducted on a monthly basis.

*****REPORT CONTINUED ON LIC809-C*****

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 12/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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 (BEACH)
FACILITY NUMBER: 198602601
VISIT DATE: 12/02/2023
NARRATIVE
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Staffing: A total of twenty six (26) staff members including the Administrators provide care and supervision to the clients. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility.

Personnel Records/Staff Training: Reviewed files for three (3) staff. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Administrator certificate is valid and expiring on 03/21/2024. Administrator has a valid HIV/AIDS training proof at the time of visit.

Client Rights-Information: Client personal rights are posted. Per Administrator, facility provides internet services to all clients and have access to the facility phone. Administrator also stated one of the clients have a personal cell phone and (3) out of (4) clients have their own tablet. LPA conducted (30 client interviews.

Client Records-Incident Reports: LPA reviewed Client files for C1 through C4. Client files are maintained at the facility. Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Individual Program Plan (IPP), Behavioral Reports, Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights observed. Food Service: There are sufficient food supplies of 2-day perishable and 7-day non-perishable items. The food is properly stored in the refrigerator (clean and well maintained). There is (1) client with special diet residing at this facility. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services: The medications are centrally stored and in their original containers. Medications were reviewed for C1-C4 to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document medications given. LPA observed that a morning medicaiton for one of the clients had been administered but it was not properly documented on the MAR. Medications are administered as prescribed by the Physician. Medications are bubbled packed.

Incidental Medical Services: Per the Administrator, there is (1) client at this home with a restricted health condition.

Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan.

Emergency Intervention: Not-Applicable.

Deficiencies cited on LIC 809D. Exit interview, appeals rights and a copy of this report was provided to the Administrator, Anna Marie Tomilloso.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/02/2023 01:32 PM - It Cannot Be Edited


Created By: Bennette Pena On 12/02/2023 at 01:21 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 (BEACH)
FACILITY NUMBER: 198602601

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(C)
80075 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, providing all of the following requirements are met:
(C) A record of each dose is maintained in the client's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the client's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the Administrator did not comply with the section cited above in that the facility staff administered (1) medication (Tamsulosin HCL 0.4mg capsule) for Client #1 for a.m. cycle but was not recorded on MAR properly which poses an immediate health, ssafety,or personal rights risk to clients in care.
POC Due Date: 12/04/2023
Plan of Correction
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Administrator will ensure medication provided to the clients is on cycle and recorded properly by staff on Medication Administration Record (MAR) sheet and re-train staff on medication. Proof of training along with the topics discussed, signed and dated by staff shall be submitted to CCL/LPA by POC due date.
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:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 12/02/2023 01:32 PM - It Cannot Be Edited


Created By: Bennette Pena On 12/02/2023 at 01:26 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 (BEACH)
FACILITY NUMBER: 198602601

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(e)(2)(B)
80075 Health Related Services
(e) In adult CCFs, when a client requires oxygen the licensee is responsible for the following:
(2) Ensuring that the following conditions are met if oxygen equipment is in use
(B) "No Smoking - Oxygen in Use" signs shall be posted in appropriate areas.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the Administrator did not comply with the section cited above in that Client #4 (C4) in bedroom #4 has oxygen tank/concentrator inside his bedroom but did not have oxygen in use signage which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 12/08/2023
Plan of Correction
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Administrator shall place an oxygen sign on the client's door and submit picture proof to CCL/LPA by POC due date.

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:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2023


LIC809 (FAS) - (06/04)
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