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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603128
Report Date: 11/14/2022
Date Signed: 11/14/2022 01:58:07 PM

Document Has Been Signed on 11/14/2022 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:AZUSA HOMEFACILITY NUMBER:
198603128
ADMINISTRATOR:HOLLAND, TRAVISFACILITY TYPE:
735
ADDRESS:722 W 6TH STTELEPHONE:
(626) 633-1610
CITY:AZUSASTATE: CAZIP CODE:
91702
CAPACITY: 3CENSUS: 2DATE:
11/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:29 AM
MET WITH:Yolanda Ramirez, DSP TIME COMPLETED:
02:08 PM
NARRATIVE
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 Licensing Program Analyst (LPA) Alberto Lopez conducted a case management visit to follow up regarding incident report submitted to the department on 10/25/22. LPA Lopez met with Yolanda Ramirez DSP and explain the reason for the visit.

On 11/14/2022 LPA Lopez conducted a case management visit to follow up on incident report submitted on 10/25/22 to report an injury that client sustained that required medical treatment. On 10/25/2022 facility reported to the department via faxed incident report and SOC 341 that on the evening of 10/24/22 resident #1 (R1) had become agitated and during the course of the incident got injured on forehead that required 4 stiches. On 11/14/22 LPA Lopez interviewed Administrator Jesse Aldrerete, DSP Yolanda Ramirez, DSP S2, S1, and R2 and attempted to interview R1 without success. LPA Lopez took photos of R1 IPP report date: 08/30/2021, face sheet, personnel record for S1. S1 is currently off schedule until internal investigation is concluded.. On 11/14/2022 LPA contacted R1 responsible party and interviewed responsible party,


No further investigation is needed at this time. deficiencies have been noted during this visit. Please see 809D for details.

Exit interview conducted with Yolanda Ramirez, DSP and a copy of this report was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2022
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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Document Has Been Signed on 11/14/2022 01:58 PM - It Cannot Be Edited


Created By: Alberto Lopez On 11/14/2022 at 01:19 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: AZUSA HOME
FACILITY NUMBER: 198603128

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/18/2022
Section Cited
CCR
80087(a)

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Buildings and Grounds. The facility shall be kept clean, sanitary and in good repair at all times.

This requirement has not been met as evidenced by:
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Licensee will replace facet in bathroom, remove and replace broken mirror in bathroom, remove empty boxes and broken storage container from side of home, repair broken door frame and replace 2 broken windows on garage door by POC date and send proof to LPA.
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LPA and DSP observed Bathroom facet that did not function properly, broken mirror in bathroom, door frame broken in living room. 2 large empty boxes on side of home and one broken plastic container on the other side of home that poses health and safety risk to clients in care.
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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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2022


LIC809 (FAS) - (06/04)
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