<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603036
Report Date: 08/16/2022
Date Signed: 08/16/2022 07:15:57 PM

Document Has Been Signed on 08/16/2022 07:15 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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:ALPHA OMEGA IIIFACILITY NUMBER:
198603036
ADMINISTRATOR:HARRIS, YAOUNDEFACILITY TYPE:
735
ADDRESS:3484 OLYMPIAD DRTELEPHONE:
(323) 620-8777
CITY:VIEW PARKSTATE: CAZIP CODE:
90043
CAPACITY: 4CENSUS: 4DATE:
08/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Administrator - Yaounde Harris/Caregiver Katherine TavaiTIME COMPLETED:
04:00 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
On 08/16/2022, Licensing Program Analyst (LPA) Don Senaha conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with caregiver Katherine Tavai and later joined by Licensee Yaounde Harris and explained the purpose of today’s visit. The facility is licensed to operate for four (4) ambulatory developmentally disabled adults of between the ages of 18 through 59.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) client rooms, three (3) bathrooms, living area, a dining area and kitchen. There is an outside patio area in the backyard. The garage is detached and used for storage only, including PPE, but used mostly for the owner of the premises. The laundry area is located next to the kitchen.

LPA and Licensee toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms fixtures were operational. The water temperature did not meet Title 22 standards in the bathrooms and kitchen sink. See 809D page. A comfortable temperature was maintained in the facility.

LPA observed the facility to be appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly. There are two (2) fire extinguisher fully charge located near the dining room and in the main hallway leading to the clients rooms. Smoke detectors and carbon monoxide were operable and in working condition. A reviewed of Medication Records Administration (MAR) was observed to be maintained in order and accurate.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
Document Has Been Signed on 08/16/2022 07:15 PM - It Cannot Be Edited


Created By: Don Senaha On 08/16/2022 at 02:30 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ALPHA OMEGA III
FACILITY NUMBER: 198603036

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. The water temperature in the kitchen sink measured 137.7F and shared bathroom measured 138.9F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/17/2022
Plan of Correction
1
2
3
4
Licensee to adjust water temperature in water heater to meet Title 22 regulations.
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Don Senaha
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2022


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 08/16/2022 07:15 PM - It Cannot Be Edited


Created By: Don Senaha On 08/16/2022 at 02:30 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ALPHA OMEGA III
FACILITY NUMBER: 198603036

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. The shared bathroom had a broken cabinet under the sink, the bedroom had a hanging light out of the wall and the clients rooms had dirty clothes and rubish on the floors and tossed in the closet which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2022
Plan of Correction
1
2
3
4
Licensee to fix the broken cabinet and hanging light and email pictures of both fixed. Licensee to send pictures of each room cleaned and closet space cleaned.
Type B
Section Cited
CCR
80066(a)(12)(B)1
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) For employees that are required to be fingerprinted pursuant to Section 80019: (B) Documentation of either a criminal record clearance or exemption as required by Section 80019(e). 1. For Certified Administrators, a copy of their current and valid Administrator Certification meets this requirement.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record reviews, the licensee did not comply with the section cited above. The administrator certificate posted was expired July 2021 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2022
Plan of Correction
1
2
3
4
LIcensee to send LPA via email a picture of the current administrator certificate posted in the facility.
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Don Senaha
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2022


LIC809 (FAS) - (06/04)
Page: 6 of 6
Document Has Been Signed on 08/16/2022 07:15 PM - It Cannot Be Edited


Created By: Don Senaha On 08/16/2022 at 02:30 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ALPHA OMEGA III
FACILITY NUMBER: 198603036

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80072(a)(2)
Personal Rights
(a) Except for children's residential facilities, each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. The Licensee did not have the "See something say something" poster posted in the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2022
Plan of Correction
1
2
3
4
LIcensee to send LPA an email picture of the poster posted in the facility.
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Don Senaha
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2022


LIC809 (FAS) - (06/04)
Page: 3 of 6
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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ALPHA OMEGA III
FACILITY NUMBER: 198603036
VISIT DATE: 08/16/2022
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
26
27
28
29
30
31
32
During the visit, LPA observed the facility infection control practices. LPA observed hand sanitizer available and temperature taken upon entry to the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). There is a fully stocked first aid kit located in a cabinet with the clients files.

There was one (1) technical advisory issued during the visit. See 9102-TA page.

There were four (4) deficiencies cited during this inspection visit. See 809 D pages.

An exit interview was conducted and a copy of this report was provided to Licensee Yaounde Harris.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6