198603019-12-2-2023-28-AS-BPEA-CY622H-20231202160046

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603019
Report Date: 12/02/2023
Date Signed: 12/02/2023 04:01:18 PM

Document Has Been Signed on 12/02/2023 04:01 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:	DOWNEY HOME II		FACILITY NUMBER:	198603019
ADMINISTRATOR:	MILIAN, FAHIR		FACILITY TYPE:	735
ADDRESS:	9107 MARGARET ST		TELEPHONE:	(562) 682-2417
CITY:	DOWNEY	STATE: CA	ZIP CODE:	90241
CAPACITY: 4		CENSUS: 4	DATE:	12/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Beatriz Milian-Torres - Administrator		TIME COMPLETED:	05:00 PM

NARRATIVE

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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 met by Shawn Milian-Torres, Direct Support Professional (DSP) and Lazaro Milian-Torres, Direct Support Professional (DSP) and explained the purpose of the visit. Administrator Beatriz Milian Torres arrived at 2:25pm and assisted LPA with the inspection. The facility is licensed to care for (4) Developmentally Disabled Adults, ambulatory only, ages 18 through 59. All clients residing at this Specialized facility receive case management services provided by South Central LA 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 maintained. The staff stated that they use disposable gloves to clean and disinfect the high touched surfaces in the common areas. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Bathrooms have hand washing signs, soap and paper towels. Staff are adhering to infection control requirements.

Physical Plant/Environment Safety: The facility is a single storey home located in a residential neighborhood, contains a total of (3) client bedrooms, (2) bathrooms, a living room, kitchen, dining area, backyard with shaded area and detached garage. Currently, there are four (4) clients living in the facility. 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. Bathrooms have 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 it serves as activity/exercise area for the clients. The garage is equipped with billiard, play balls and other outdoor game equipment. Kitchen knives, sharps objects, cleaning supplies and toxic substances are locked and inaccessible to clients. There are (2) fire extinguishers observed to be fully charged and last serviced on March 8, 2023. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit.

Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has not been added to the Plan. A fire clearance is in place. Liability Insurance policy in the amount of $1,000,000.00 each occurrence and $3,000,000.00 in the total annual aggregate is valid and will expire on 02/14/2024. Surety Bond (Charity One) is in effect and in force. The insurance will expire on 10/15/2026. Last Fire Drill was conducted on 09/20/2023 and being conducted on a quarterly basis.

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

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2023

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: DOWNEY HOME II	FACILITY NUMBER: 198603019
	VISIT DATE: 12/02/2023

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Staffing: A total of sixteen (16) 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. LPA observed that one (1) staff member had a criminal background clearance and fingerprint cleared in 2019. However, he had a name change and clearance has not been transferred yet.

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 has expired on 09/26/2023 but has submitted the request for renewal the beginning of Sep.2023. Application is still pending, based on email proof provided by the Administrator. Administrator has a valid HIV/AIDS training proof at the time of visit.

Client Rights-Information: Client personal rights are posted. Per Administrator, facility provides internet services to all clients and have access to the facility phone. Administrator stated two (2) of the clients have a personal cell phone and (3) out of (4) clients have their own tablet. LPA conducted (2) client interviews, as the other (2) are out in the community.

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). 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 the Administrator, no client at this home has a restricted health condition.

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

Emergency Intervention: Not-Applicable.

Deficiency cited on LIC 809D. Exit interview, appeals rights and a copy of this report was provided to the Administrator, Beatriz Milian-Torres.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/02/2023 04:01 PM - It Cannot Be Edited

Created By: Bennette Pena On 12/02/2023 at 03:47 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: DOWNEY HOME II	FACILITY NUMBER: 198603019
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80019(e)(3)

80019 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records reviewed, the Administrator did not comply with the section cited above in which Staff #1 (S1) file was reviewed and observed that he does not have a current criminal and fingerprint clearance under his new name on file which poses a potential health, safety or personal rights risk to Clients in care
	POC Due Date: 12/06/2023
	Plan of Correction
1 2 3 4	Administrator agreed to have S1 fingerprinted on Monday, 12/04/2023. Proof of fingerprint will be submitted to CCL/LPA for review on or before the 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:

Bennette Pena

LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2023

LIC809 (FAS) - (06/04)

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