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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602853
Report Date: 06/07/2022
Date Signed: 06/07/2022 03:50:11 PM

Document Has Been Signed on 06/07/2022 03:50 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:REDEEMER HOME-IFACILITY NUMBER:
198602853
ADMINISTRATOR:BERNAL, JOSEFINA R.FACILITY TYPE:
735
ADDRESS:1114 FORD DRIVETELEPHONE:
(626) 667-7773
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY: 6CENSUS: 5DATE:
06/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:41 PM
MET WITH:Josefina Bernal, AdministratorTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with staff Mary Ann Veses and explained the purpose of the visit. Administrator Josefina Bernal arrived shortly after. There are five (5) clients level 4C developmentally disabled clients ages 59 and under. Facility is a single story home licensed for 6 ambulatory only clients. It is located in a residential area consisting of three (3) shared client bedrooms, 2 bathrooms, kitchen, dining room, living room, covered patio area, and laundry area in the attached garage. The last emergency disaster drill was completed on 2/21/2022. Administrator certificate expires 2/23/2023.

The following were observed/inspected:
  • COVID-19 Infection Control Practices were observed upon entry and in common areas and LPA was screened upon entry. Two (2) caregiver staff at the facility were observed not wearing surgical masks.
  • Infection control signs, and other signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • Room #3 is designated as COVID-19 isolation room if needed.
  • Hand sanitizer was observed in common areas.
  • Clients were not observed wearing masks in the home due to cognitive impairment.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
  • A Emergency Disaster Plan was posted. Please update if needed.
  • Sufficient supply of Personal Protective Equipment (PPEs) was observed.
  • Centrally stored medication records were reviewed.
  • The right side of the property has discarded wood planks and the patio area is missing 2 pavers on the floor that may be tripping hazards to clients in care and staff.
A deficiency was cited.
Exit interview was conducted with Josefina Bernal. A copy of the report and appeal rights was issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2022
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 06/07/2022 03:50 PM - It Cannot Be Edited


Created By: Noemi Galarza On 06/07/2022 at 03:37 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: REDEEMER HOME-I
FACILITY NUMBER: 198602853

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

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 in that the right side of the yard has discarded wood planks and two pavers by the backyard patio are missing, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2022
Plan of Correction
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Licensee agrees to discard the debris and install missing pavers by the patio area. Submit picture proof of corrections.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2022


LIC809 (FAS) - (06/04)
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