198603128-5-31-2022-28-AS-NMAN-CEXRRL-20220531131519

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603128
Report Date: 05/31/2022
Date Signed: 05/31/2022 01:48:12 PM

Document Has Been Signed on 05/31/2022 01:48 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	AZUSA HOME		FACILITY NUMBER:	198603128
ADMINISTRATOR:	HOLLAND, TRAVIS		FACILITY TYPE:	735
ADDRESS:	722 W 6TH ST		TELEPHONE:	(626) 633-1610
CITY:	AZUSA	STATE: CA	ZIP CODE:	91702
CAPACITY: 3		CENSUS: 3	DATE:	05/31/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Assistant Administrator Jose Alderete		TIME COMPLETED:	01:00 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	Licensing Program Analyst (LPA) Nune Margaryan conducted an annual required visit. LPA met with Assistant Administrator Jose Alderete and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. The physical plant was inspected along with COVID-19 procedures, medications, food supply, and clients and staff records. The facility has an approved mitigation plan on file. The facility is licensed to serve developmentally disable clients between the ages 18 to 59 and vendorized by San Gabriel/Pomona Regional Center. LPA toured the home and inspected three (3) client bedrooms, two (2) bathrooms, kitchen, dining / living room, office, and attached garage. Laundry area is located in the garage. There is a metal cabinet in the garage for laundry detergent and chemicals. During the inspection LPA observed that metal cabinet was unlocked and laundry detergent and chemicals were accessible to clients. There are no pools or large bodies of water. Passageways and exits are free of obstruction. There is only one entrance being utilized at the facility, all required posters were posted at the entrance. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing mask upon entrance and during visit. All client bedrooms were toured. Each bedroom has a bed, linen, dresser, light, and sufficient closet space. The client bathrooms were clean and the hot water was tested 110.7 and 111. 8 degrees which is within the required 105 - 120 degrees. The kitchen was inspected. There is sufficient 2 days perishable and 7 days non-perishable food. All the appliances are clean and seem to be operating properly. Sharps are locked in a closet in the hallway and are inaccessible to clients. There is a fire extinguisher located in the kitchen and it is fully charged. Each bedroom has a smoke detector. There is a carbon monoxide detector in the hallway of the home. Continue 809C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022

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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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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: AZUSA HOME	FACILITY NUMBER: 198603128
	VISIT DATE: 05/31/2022

NARRATIVE

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LPA observed the centrally stored medication area to be locked and inaccessible to clients. The first aid kit was observed and found to be in compliance with the Title 22 Regulations.

LPA reviewed resident files to confirm emergency contacts have been updated. LPA confirmed staff working have fingerprint clearances. LPA reviewed clients medications. Medications are documented and stored properly.

Per California Code of Regulations, Title 22, the deficiencies observed are documented on the attached 809D.

Exit interview held. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/31/2022 01:48 PM - It Cannot Be Edited

Created By: Nune Margaryan On 05/31/2022 at 12:53 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: 05/31/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(g)

Buildings and Grounds. Disinfectants, cleaning solutions, poisons, and other items that could pose a danger to clients shall be inaccessible. 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. LPA observed that metal cabinet in the laundry are / garage was unlocked, and laundry detergent and chemicals were accessible to clients, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/31/2022
	Plan of Correction
1 2 3 4	Citation was cleared at the time of visit. No further action is needed.

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:

Wei Siew Ho

LICENSING EVALUATOR NAME:

Nune Margaryan

LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022

LIC809 (FAS) - (06/04)

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