198602875-5-20-2023-28-AS-BPEA-CRZVXK-20230520164941

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602875
Report Date: 05/20/2023
Date Signed: 05/20/2023 04:49:51 PM

Document Has Been Signed on 05/20/2023 04:49 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:	CASA BARBARA		FACILITY NUMBER:	198602875
ADMINISTRATOR:	HENRY A LARA		FACILITY TYPE:	735
ADDRESS:	3453 LIBERTY BOULEVARD		TELEPHONE:	(562) 682-9667
CITY:	SOUTH GATE	STATE: CA	ZIP CODE:	90280
CAPACITY: 4		CENSUS: 4	DATE:	05/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Yusimi Travieso, Licensee/Administrator		TIME COMPLETED:	05:00 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 screened and met by Sarah Torres/ Direct Support Professional I & II (DSP I & II) and explained the purpose of the visit. LPA spoke to the Administrator/Licensee Yusimi Travieso on the phone and explained the reason for the visit. At 3:15pm, Licensees Pedro and Yusimi Travieso arrived and assisted LPA with the inspection. The facility is licensed to care for (4) Developmentally Disabled Adults, ages 18 through 59, ambulatory only. All clients residing at this facility receive case management services provided by South Central Los Angeles 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 observed. There is a visitor screening station at the entrance of the facility. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Facility does not have COVID-19 signage posted in the facility. Bathrooms have soap and paper towels. Staff are adhering to infection control requirements.

Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. A fire clearance for (4) clients is in place. Surety Bond Insurance (Western Surety Company) is in effect. Fire Drill was conducted on 03/22/2023.

Physical Plant/Environment Safety: The facility is a single storey home located in a residential neighborhood, contains a total of (3) client bedrooms and (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. Facility is Level 4I. 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. Bathroom has 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 has a shaded area and sitting area. Detached garage was inspected and LPA observed that one of the garage doors is broken. S1 stated that a repairman has been contacted and is scheduled to fix it on Mon., 5/22/2023. Kitchen knives, sharps objects, cleaning supplies and toxic substances are locked in a cabinet and inaccessible to clients. There is a fire extinguisher observed to be fully charged and was last serviced on June 24, 2022. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. There are no cameras in the facility. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Hot water supply measured 109.6 deg F in the kitchen, 116.4 deg F in bathroom #1 and 118.2 deg F in bathroom #2.

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

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CASA BARBARA	FACILITY NUMBER: 198602875
	VISIT DATE: 05/20/2023

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Staffing: A total of six (6) staff members including the Administrator 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 06/29/2024. Administrator has a valid HIV/AIDS training proof at the time of visit.

Client Rights-Information: Client personal rights are posted. Per S1, facility provides internet services to all clients and have access to the facility phone. S1 also stated three (3) out of four (4) clients have a personal cell phones and (1) out of (4) clients has a tablet/IPad. LPA conducted (3) 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 are no clients with special diets 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. Medications are administered as prescribed by the Physician. Medications are bubbled packed.

Incidental Medical Services: Per S1, there are no clients at this home with incidental medical services nor have a restricted health condition.

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

Emergency Intervention: Not-Applicable.

No deficiencies cited. Exit interview and a copy of this report was provided to the Administrator/Licensee, Yusimi Travieso.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2023

LIC809 (FAS) - (06/04)

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