198603035-10-4-2024-28-AS-DKOI-D9QSL5-20241004135746

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603035
Report Date: 10/04/2024
Date Signed: 10/04/2024 01:58:00 PM

Document Has Been Signed on 10/04/2024 01:58 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	PUENTE HOME		FACILITY NUMBER:	198603035
ADMINISTRATOR/ DIRECTOR:	MELISSA VAZQUEZ		FACILITY TYPE:	737
ADDRESS:	1423 E PUENTE AVE		TELEPHONE:	(626) 331-6331
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91791
CAPACITY: 4		CENSUS: 4	DATE:	10/04/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:25 AM
MET WITH:	Melissa Vasquez, Administrator		TIME VISIT/ INSPECTION COMPLETED:	02:10 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) Daniel Konishi conducted the required annual inspection. LPA arrived unannounced and met with Administrator Melissa Vazquez allowed the entry of the facility and assisted with the visit. The purpose for the visit was explained. The facility is licensed for Age Range 18 through 59. 4 ambulatory which 3 maybe non-ambulatory. Non-ambulatory in bedrooms 1,2 &3. The facility is vendored as an Enhanced Behavioral Support Home (EBSH) with San Gabriel Pomona Regional Center. There are currently 4 clients in the facility. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and only inspected those domain: 1. Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting at least once a day and more often for high touched surfaces. Facility has sufficient PPE supplies and has an Infection Control Plan. 2. Physical Plant and Environmental Safety: The facility is a single story house and located in a residential neighborhood area. The facility includes: Living room#1, Living room#2, dining area, kitchen, open staff office, four clients bedrooms, two clients bathrooms and an attached garage. Each client bedroom has one bed, one chair, one drawer, one night stand, required furniture and beddings and sufficient lighting and closet space. The two client bathrooms are clean, sanitary and in a good working condition. The hot water in two client bathroom were read at 105 degrees F. which is within Title 22 regulation. All the knives and sharp utensils are stored and locked in the medication cart. All the cleaning supplies and chemicals are stored and locked in the cabinet near the living room#1. The extra personal hygiene products are stored and locked in the cabinet in the garage.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024

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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PUENTE HOME	FACILITY NUMBER: 198603035
	VISIT DATE: 10/04/2024

NARRATIVE

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The extra linen and towels are stored in the cabinet near the living room#1. The facility would turn on the hallway light for client to access the non-private bathrooms at night. The facility has a land-line telephone system. Fire extinguisher was observed in the kitchen and last reviewed 05/15/2024. LPA inspected the carbon monoxide detectors and smoke detectors and they are interconnected and they are working properly. The walkway, passageway and patio are free of obstruction.

3. Operational Requirement: The fire clearance is approved for 1 ambulatory and 3 non-ambulatory. Currently all clients are ambulatory. Facility does have a Enhanced Behavioral Support Home folder in place. The last fire and disaster drill was conducted on 07/17/2024. The facility has a patio with a shaded area with table and chairs for client to utilize for outdoor activity.

4.Client's right-Information: Currently the facility does not have any postural support clients. The facility does serve adults with internet service with at least one internet access device that they can support with real time interactive application like face time with their family or zoom meeting with their day program.

5. 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. Currently, no client is on modified diet that prescribed by a physician.

6. Incidental Medical Services: Currently the facility has no client with prohibited health condition and one of the clients in the facility has a restricted health care plan on file.

7.Health Related Services: The client's medication are stored and locked in the medication cart. LPA inspected all four (4) clients medications and they are seemed updated and accurate and they all have 30 days supply of mediation. Facility staff would provide transportation for client's medical and dental appointment.

8.Staffing: The facility has sufficient staffing in the facility. LPA reviewed the NOC shift staff file and they have the required training for facility planned emergency procedure.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024

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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PUENTE HOME	FACILITY NUMBER: 198603035
	VISIT DATE: 10/04/2024

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9. Personnel Records-Training: All the staff in the facility are over 18 years old, fingerprint cleared and associated with the facility. The administrator of the facility is Melissa Vasquez and she has all the requirement or prior experience to become an administrator of the facility. Her administrator expiration date: 5/31/26. She does have the updated HIV and TB training certificate. All the staff files have the required documents in their files which is included criminal background clearance, updated health screening, TB test result, CPR/CPI certifications, employee application, and required training hours and updated first aid certificate.

10. Client Records-Incident reports: LPA reviewed all four (4) clients files and they all have the required documents include the updated monthly individual behavioral support plan, Identification and Emergency Information, face sheet, physician report, TB test result, ambulatory status, individual program plan (IPP), preplacement appraisal, admission agreement, immunization record, functional capabilities assessment, Appraisal/Needs and Services Plan, Personal Rights, medication list.

11. Disaster Preparedness: The facility has an emergency disaster plan in place but not updated. The last fire and disaster drill was conducted on 07/17/2024. The facility has two alternative shelter locations.

12. Emergency Intervention Plan: The facility would use restraint for the last resources and all staff has an updated CPI training hours.

No deficiencies were observed during the visit. Exit Interview conducted and a copy of the report was provided to Administrator Melissa Vazquez.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024

LIC809 (FAS) - (06/04)

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