198602931-9-29-2023-28-AS-CWOG-CW5PT7-20230929113527

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602931
Report Date: 09/29/2023
Date Signed: 09/29/2023 11:36:32 AM

Document Has Been Signed on 09/29/2023 11:36 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	JOSHUA TREE HOME		FACILITY NUMBER:	198602931
ADMINISTRATOR:	JASMIN TOMINES		FACILITY TYPE:	735
ADDRESS:	18207 VILLA CLARA STREET		TELEPHONE:	(626) 295-2197
CITY:	ROWLAND HEIGHTS	STATE: CA	ZIP CODE:	91748
CAPACITY: 6		CENSUS: 6	DATE:	09/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Alvin Capanzana		TIME COMPLETED:	12:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Wong conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with DSP Elisa Apo and explained the reason of the visit. Shortly after, the administrator Alvin Capanzana arrived and assisted with the facility visit. The facility is approved for serve Developmentally Disabled Adults, age 18 through 59, 6 ambulatory, of which 2 may be non-ambulatory. The facility is licensed as a Level 4C home vendored by San Gabriel Pomona Regional Center. The following twelve (12) tool domains were observed and reviewed: Infection Control, Physical Plant/Environmental Safety, Operational Requirements, Staffing, Personal Records-Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incidental Medical Services, Disaster Preparedness and Emergency Intervention. 1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility still encourages hand washing, still checking client temperature twice a day and staff disinfected the facility every shift. The facility has an Infection Control Plan and COVID-19 mitigation plan in place. 2. Physical Plant-Environmental Safety: The facility is a single story house and located in a residential neighborhood area. The facility includes living room, kitchen, dining area, five clients bedrooms and two clients bathrooms, staff office and an attached garage. Bedroom#1 - #4 has one bed, one chair, one night stand, one drawer, required furniture and beddings and sufficient lighting and closet space. Bedroom#5 has two beds, two chairs, two night stands, two drawers, required furniture and beddings and sufficient lighting and closet space. The two clients bathrooms are clean, sanitary and in a good working condition. The hot water temperature in two clients' bathrooms were tested between 111.7 and 113 degrees F which are within the Title 22 regulation (See LIC 809C for continuation)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

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: JOSHUA TREE HOME	FACILITY NUMBER: 198602931
	VISIT DATE: 09/29/2023

NARRATIVE

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The appliances in the kitchen and living room are working properly. The knives and sharp utensils are stored and locked in the kitchen drawer. The cleaning supplies and chemicals are stored and locked under the sink and supply room in the garage. The extra linen and personal hygiene products are stored in the hallway cabinet. The hallway light is always on during night time for client to access the non-private bathrooms. The facility has a land line telephone system for client to access. LPA also inspected the carbon monoxide detectors and smoke detectors and they are all working well. The passageway, walkway and patio are free of obstruction.

3. Operational Requirements: The facility is cleared for 6 ambulatory and which 2 may be non-ambulatory. Currently two clients are non-ambulatory and they are maintained the fire clearance requirement. The last fire /earthquake drill was conducted on 09/04/23. The facility has a shaded area in the patio with table and chairs for client to utilize outdoor activity. The facility would allow client to attend the community activities if there's an opportunity or chance.

4. Staffing: The facility has sufficient staffing in the facility. LPA also inspected the NOC shift staff and he has the required facility planned emergency procedure training in files.

5. Personnel Records-Training: The staff files are stored and locked in the drawer in the staff office. LPA inspected four staff files and they all have the required documents included health screening, TB Test result, required training hours and updated first aid certificate. The administrator are Dr. Antonio Arboleda and Alvin Capanzana and they both do not have an updated HIV and TB training certificate. Alvin Capanzana administrator certificate expiration date : 11/16/2024. And Dr. Antonio Arboleda was expired on June 13, 2023 but his administrator certification application is pending in CCL system at the present time.

6. Client's Right-Information: Currently the facility has no client is required postural support. The facility would provide internet service and at least one internet access device for communicating with client's family members or day program.

7. Client's Records-Incident Reports: The clients files are stored in the staff office in a cabinet. LPA reviewed all six (6) client's files and they all have the required documents included: Face sheet, Admission agreement, Functional Capabilities Assessment, Individual Program Plan (IPP), Updated physician report, TB Test result, medication list and ambulatory status.

(See LIC 809C for continuation)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

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: JOSHUA TREE HOME	FACILITY NUMBER: 198602931
	VISIT DATE: 09/29/2023

NARRATIVE

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8. Food Service: The facility has ample supply of 2 days perishable and 7 days non-perishable food supply. All the food are stored properly in the facility. The temperature in the refrigerator is maintained within the required temperature.

9. Health Related Services: The facility would assist client with medical and dental appointment. The medication is centrally stored and locked in the medication cabinet near the kitchen. LPA inspected all six (6) clients medication and they all seemed updated and accurate. All clients have 30 days supply of medication.

10. Incidental Medical Services: At the present time, no client in the facility is on restricted health condition plan or prohibited health condition.

11. Disaster Preparedness: The facility has an updated Emergency Disaster Plan (LIC610D) dated on 8/4/23 and its posted in the living room. The facility has two temporary alternative shelter location. The last fire/earthquake drill was conducted on 9/4/23.

12. Emergency Intervention: The facility does not use any restraint on clients but all staff have the updated CPI training.

The following deficiencies are being cited on the attached LIC 809D page, California Code of Regulations, Title 22, Division 6, Chapter 1.

Exit interview conducted with Administrator Alvin Capanzana and a copy of this report is being provided and Appeal Rights were given.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/29/2023 11:36 AM - It Cannot Be Edited

Created By: Christine Wong On 09/29/2023 at 11:10 AM

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: JOSHUA TREE HOME	FACILITY NUMBER: 198602931
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85064(k)

Administrator Qualifications and Duties

(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, LPA did not observe the administrator has received the HIV and TB Training which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/13/2023
	Plan of Correction
1 2 3 4	The administrator will send the updated HIV and TB Training certificate to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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:

David Sicairos

LICENSING EVALUATOR NAME:

Christine Wong

LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

LIC809 (FAS) - (06/04)

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