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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603036
Report Date: 11/09/2023
Date Signed: 11/09/2023 12:27:18 PM

Document Has Been Signed on 11/09/2023 12:27 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
EL SEGUNDO, 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) 792-4199
CITY:VIEW PARKSTATE: CAZIP CODE:
90043
CAPACITY: 4CENSUS: 4DATE:
11/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:02 AM
MET WITH:Licensee Yaounde Harris via Telephone & Katherine TavaiTIME COMPLETED:
01:20 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 11/09/2023 at 8:02 am Licensing Program Analyst (LPA) David España conducted an unannounced Required-1-year annual visit. Upon arrival at the facility, LPA España conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection (No COVID-19 cases). LPA verified that the facility has an approved mitigation plan report. LPA was granted access and allowed to enter the facility to conduct the inspection.

LPA met with caregiver Katherine Tavai and later joined via telephone 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 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 staff 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 were observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms fixtures were operational. The water temperature did meet Title 22 standards in the bathrooms and kitchen sink. 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. Continued on LIC-809D
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2023
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 4
Document Has Been Signed on 11/09/2023 12:27 PM - It Cannot Be Edited


Created By: David Espana On 11/09/2023 at 11:44 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ALPHA OMEGA III
FACILITY NUMBER: 198603036

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80022(e)(4)
Plan of Operation
(e) If the licensee intends to admit or care for one or more clients who rely upon others to perform all activities of daily living, the plan of operation must also include a statement that demonstrates the licensee's ability to care for these clients. The evidence of ability may include but not be limited to: (4) Documentation of training the licensee and/or staff have completed specific to the needs of these clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the sectio cited above. LPA and caregiver Katherine Tavai observed Staff #1-#5 (S#1-#5) did not have current CPR/1st Aid. LPA and caregiver Katherine Tavai observed no current Administrator certification for S#2, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/17/2023
Plan of Correction
1
2
3
4
Administrator will provide proof Staff #1-#5 (S#1-#5) have current CPR/1st Aid and provide a written plan to ensure that staff have all documentation relating to 1st Aid certification (david.espana@dss.ca.gov).
Type B
Section Cited
CCR
85064(b)
Administrator Qualifications and Duties
(b) All adult residential facilities shall have a qualified and currently certified administrator.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above. LPA and caregiver Katherine Tavai observed no current Administrator certification for S#2, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/24/2023
Plan of Correction
1
2
3
4
Administrator will provide proof of current Administrator certification and provide a written plan to ensure that staff/Administrator have all documentation relating to Administrator certification current at all times at the facility and posted (david.espana@dss.ca.gov).
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:Ulysses Coronel
LICENSING EVALUATOR NAME:David Espana
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/09/2023 12:27 PM - It Cannot Be Edited


Created By: David Espana On 11/09/2023 at 11:44 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ALPHA OMEGA III
FACILITY NUMBER: 198603036

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above.LPA and caregiver Katherine Tavai observed Staff #1-#5 (S#1-#5) did not have current CPR/1st Aid, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/17/2023
Plan of Correction
1
2
3
4
Administrator will provide proof Staff #1-#5 (S#1-#5) have current CPR/1st Aid and provide a written plan to ensure that staff have all documentation relating to 1st Aid certification (david.espana@dss.ca.gov).
Type B
Section Cited
HSC
1565(a)(5)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (5) At least two appropriate shelter locations that can house or supervise, as applicable, individuals served by the facility during an evacuation. One of the locations shall be outside of the immediate area.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above. LPA and caregiver Katherine Tavai did not observe Emergency Disaster Plan LIC610D updated 2023 record, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/17/2023
Plan of Correction
1
2
3
4
Administrator will provide proof of Emergency Disaster Plan LIC610D updated of 2023 and provide a written plan to ensure that staff/facility is current with all documentation relating to Emergency Disaster Plan LIC610D (david.espana@dss.ca.gov).
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:Ulysses Coronel
LICENSING EVALUATOR NAME:David Espana
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ALPHA OMEGA III
FACILITY NUMBER: 198603036
VISIT DATE: 11/09/2023
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
Per staff at the time of visit on 11/09/2023 no clients in care receive medication and there was no review of Medication Records Administration (MAR) to observe.

There were four (4) deficiencies cited during this inspection visit. See LIC809-D pages.



Operational Requirements - Type B: 80022(e)(4)
Personnel Records - Training - Type B: 85064(b)
Personnel Records - Training - Type B: 80075(f)
Disaster Preparedness - Type B: 1565(a)(5)

An exit interview was conducted, and a copy of this report was provided to caregiver Katherine Tavai.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4