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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602853
Report Date: 06/04/2024
Date Signed: 06/04/2024 12:07:53 PM

Document Has Been Signed on 06/04/2024 12:07 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/
DIRECTOR:		BERNAL, JOSEFINA R.FACILITY TYPE:
735
ADDRESS:1114 FORD DRIVETELEPHONE:
(626) 667-7773
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY: 6CENSUS: 5DATE:
06/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Josefina Bernal, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Noemi Galarza made an unannounced annual inspection visit. The purpose of the visit was explained to DSP Mary Ann Veses. The facility is an Adult Residential Facility (ARF) that serves level 4b developmentally disabled residents ages 59 and under, vendored by San Gabriel/Pomona Regional Center. The facility is a single story home located in a residential neighborhood that is licensed for six (6) ambulatory only residents. The home consists of three (3) client bedrooms, 2 bathrooms, kitchen, dining room, living room, backyard & side yard with patio area, and an attached garage with laundry area. The following 12 (CARE) tool domains were utilized during the inspection.

Infection Control: The facility staff are using appropriate hand hygiene cleaning and disinfecting the home. An Infection Control Plan was reviewed. Visit screening is still in place.

Physical Plant/Environment Safety: The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors were tested and are operation. The facility has one (1) fully charged fire extinguisher. Hot water temperature readings measured between the required 105 - 120 degrees Fahrenheit. Storage areas for cleaning solutions/toxins, knives, and hazardous items were inaccessible to clients.

Operational Requirements: Fire clearance is approved for six (4) ambulatory only residents. Care and supervision to meet the clients needs was observed. No special equipment and supplies are used by clients. Facility manages residents P & I monies. The Surety Bond is current.



Staffing: A total of five (5) staff members provide care and supervision to the clients.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/04/2024
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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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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: REDEEMER HOME-I
FACILITY NUMBER: 198602853
VISIT DATE: 06/04/2024
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Personnel Records/Staff Training: Five (5) staff files were reviewed and contained criminal background clearance, in-service training, 1st Aid/CPR training, and health screening. Administrator certificate expires 2/25/2025.

Resident Rights/Information: Resident Personal Rights poster is posted in the dining area. Internet access is available for residents. Physician's orders are on file. Three (3) residents have modified diet orders.

Resident Records/Incident Reports: Five (5) resident files were reviewed containing admission agreements, Physician's Reports, IPPs, medical/functional assessments, Behavior Reports, TB clearance, personal rights, medical consent, medication records, and P & I trust records.

Food Service: The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.

Health Related Services: Residents are assisted with self administration of prescription and non-prescription medications. Medications records were reviewed. Centrally stored medications are kept in a safe and locked place not accessible to clients in care. Medications are given according to Physician directions. 30-Day supply of medications were observed.

Incident Medical and Dental: All residents have a Needs and Services Plan and updated medical assessments.

Disaster Preparedness, and Emergency Intervention: A current LIC 610D updated form "Emergency Disaster Plan/Disaster and Mass Casualty Plan LIC 610D was reviewed.

The last Fire/Emergency Drill was conducted on 2/1/2024.

Emergency Intervention: No manual restraints, seclusion, or de-escalation techniques are used.

No deficiencies were observed.



Exit interview was conducted with Josefina Bernal. A copy of the report was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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