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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602627
Report Date: 03/30/2022
Date Signed: 03/31/2022 06:41:26 AM

Document Has Been Signed on 03/31/2022 06:41 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME:CALIFORNIA MENTOR - 230TH STREET HOMEFACILITY NUMBER:
198602627
ADMINISTRATOR:ROSAS, CLAUDIOFACILITY TYPE:
735
ADDRESS:434 W 230TH STREETTELEPHONE:
(909) 483-2505
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 3CENSUS: 2DATE:
03/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:48 PM
MET WITH:MARTEL PLOTNICKTIME COMPLETED:
04:29 PM
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On 03/30/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with Program Manager Martel Plotnick. LPA explained the purpose of today’s visit. The facility is licensed to operate for three (3) non-ambulatory ages 18 through 59. The clients are Harbor Regional Center consumers.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: three (3) client's rooms, two (2) common bathrooms, a living area, dining area, kitchen, and outside patio area.

LPA toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 109.7 F. A comfortable temperature of 73 degrees was maintained in the facility.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, and toxins are not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. A fire extinguisher was charged, smoke detectors and carbon monoxide were operable. A review of Medication Records Administration (MAR) and Fire Drills were observed to be maintained in order and accurate. The last fire drill was conducted on 3/24/22.

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2022
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 03/31/2022 06:41 AM - It Cannot Be Edited


Created By: Ernand Dabuet On 03/30/2022 at 03:31 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 DR #100
MONTERY PARK, CA 91754

FACILITY NAME: CALIFORNIA MENTOR - 230TH STREET HOME
FACILITY NUMBER: 198602627

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(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.

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 with two sharp objects (knives and scissors) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2022
Plan of Correction
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Licensee will immediately placed hazadous objects stored in a locked drawer or cabinet.
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/31/2022 06:41 AM - It Cannot Be Edited


Created By: Ernand Dabuet On 03/30/2022 at 03:31 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 DR #100
MONTERY PARK, CA 91754

FACILITY NAME: CALIFORNIA MENTOR - 230TH STREET HOME
FACILITY NUMBER: 198602627

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 where (1) kitchen drawer with a broken lock and the other with a broken slider, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/13/2022
Plan of Correction
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Licensee will adhere to Title 22 regualtions section 80087 and will repair broken lock and kitchen drawers by POC 04/13/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Eva M Alvarez
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022


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 DR #100
MONTERY PARK, CA 91754
FACILITY NAME: CALIFORNIA MENTOR - 230TH STREET HOME
FACILITY NUMBER: 198602627
VISIT DATE: 03/30/2022
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DEFICIENCIES:
LPA observed a knife and sharp scissors in an unlocked kitchen drawer accessible to clients nearby a stove. The kitchen drawer had a broken lock. LPA observed another kitchen drawer with a broken slider which will need to be repaired.

INFECTION CONTROL:
LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff and resident vaccination records was performed.

Deficiencies cited on LIC 809D.

An exit interview and a copy of this report were provided to Martel Plotnick.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
LIC809 (FAS) - (06/04)
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