198603128-5-22-2023-28-AS-EZAA-CS3VCP-20230522161929

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603128
Report Date: 05/22/2023
Date Signed: 05/22/2023 04:19:50 PM

Document Has Been Signed on 05/22/2023 04:19 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 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: 2	DATE:	05/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:51 PM
MET WITH:	Yolanda Ramirez - Caregiver		TIME COMPLETED:	04:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to Yolanda Ramirez one of the caregivers at the facility. Facility administrator Jose Alderete was notified of the inspection over phone. There are two (2) ambulatory developmentally disabled clients who reside in the home. The facility is an Adult Residential Facility (ARF) vendored by the San Gabriel/Pomona Regional Center.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention.

Infection Control:

· Infection control practices and Personal Protective Equipment (PPEs) were observed. The shared staff room may be used as a COVID-19 isolation room if necessary. The Facility administrator Jose Alderete advised that he will email his Infection Control Plan to LPA within 7 days.

Physical Plant/Environment Safety:

· The facility is a single-story home located in a residential neighborhood that is licensed for a capacity of three (3) developmentally disabled clients, of which one (1) may be non-ambulatory. It consists of 3 client bedrooms, a staff room, a living room, dining room, a kitchen, one (1) shared client bathrooms of which the non-private restroom R#1 measured at 114.7 degrees F and private restroom connected with a staff room R#2 Measured 111.5 degrees F, backyard area, and an attached garage.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023

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 05/22/2023 04:19 PM - It Cannot Be Edited

Created By: Erik Zaragoza On 05/22/2023 at 03:51 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: 05/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80077.3(a)(3)(C)

Care for Clients who Lack Hazard Awareness or Impluse Control

(C) Following the disaster and mass casualty plan specified in Section 80023, fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all facility staff who provide or supervise client care and supervision. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 out of 2 clients because the last fire drill was conducted on 4/2/2022, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/05/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator will conduct fire drills once every three months. Licensee/Administrator will provide LPA proof of the an updated Fire/Disaster Drill within 2 weeks showing it was performed within the past 3 months. Administrator will set quarterly reminders by posting a fire drill calendar as a reminder.

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:

David Sicairos

LICENSING EVALUATOR NAME:

Erik Zaragoza

LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: AZUSA HOME	FACILITY NUMBER: 198603128
	VISIT DATE: 05/22/2023

NARRATIVE

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· The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors are operational. The facility has one (1) fully charged fire extinguisher that is kept in the kitchen of the house. Cleaning supplies and toxic substances are inaccessible to clients.
· Water temperature readings measured between the required 105 - 120 degrees Fahrenheit.
Operational Requirements:
· The Program Design was reviewed.

· Fire clearance was approved by LA County Fire Department for three (3) developmentally disabled clients, of which one (1) may be non-ambulatory.

· Care and supervision to meet the clients needs was observed.
Staffing:

· A total of six (six) full-time staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

· Administrator certificate has been requested to be renewed in March of this year and administrator will follow up with LPA once it has been successfully renewed.

· Five (5) staff files were reviewed for criminal background clearance and training.
· Personnel records have health/TB screenings, CPI training, certifications, and 1st Aid/CPR training.
Client Rights/Information:

· Physician orders were reviewed in client files.

Client Records/Incident Reports:

· Five (5) client files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, IPP reports, personal rights, medical consent, nutritional assessments, medication records, and P & I money were reviewed.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: AZUSA HOME	FACILITY NUMBER: 198603128
	VISIT DATE: 05/22/2023

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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.

· No restricted Health Care plan required for the clients in the facility.

Health Related Services:

· Clients are assisted with self-administration of prescription and non-prescription medications.

· Two (2) centrally stored resident medication records were reviewed. Centrally stored medications are kept in a safe and locked place not accessible to clients in care. Medications are given according to Physician directions.

Incident Medical and Dental:

· All clients have a Needs and Services Plan, and COVID-19 vaccination cards on file.

· Staff training was on file.

Disaster Preparedness, and Emergency Intervention:

· A posted Emergency Disaster Plan LIC 610D containing emergency evacuation information was observed.

· An emergency drill was last documented and 4/2/2022 which led to a deficiency.

Emergency Intervention:

· No manual restraints or seclusion are used with clients in care.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there was one deficiency cited during the visit, please see LIC-D information for additional details. Exit interview was conducted and report provided.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023

LIC809 (FAS) - (06/04)

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