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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603128
Report Date: 05/16/2024
Date Signed: 05/16/2024 02:05:22 PM

Document Has Been Signed on 05/16/2024 02:05 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 HOMEFACILITY NUMBER:
198603128
ADMINISTRATOR/
DIRECTOR:		HOLLAND, TRAVISFACILITY TYPE:
735
ADDRESS:722 W 6TH STTELEPHONE:
(626) 633-1610
CITY:AZUSASTATE: CAZIP CODE:
91702
CAPACITY: 3CENSUS: 3DATE:
05/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Mirna AldereteTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analysts (LPA) Nune Margaryan conducted an unannounced annual visit using the Care Tool. LPA met with Program Manager Mirna Alderete. Administrator Jose Alderete arrived shortly after who assisted with the visit. LPA explained the reason for the visit.
The physical plant was inspected along with medications, food supply, and clients and staff records. The facility is licensed to serve developmentally disable clients between the ages 18 to 59 of which (2) may be ambulatory and (1) may be non-ambulatory. There are currently 3 clients residing at the home and receive services from San Gabriel / Pomona Regional Center. At the time of visit 2 clients were at the Day Program and one on home visit. LPA toured the home and inspected three (3) client bedrooms, two (2) bathrooms: one for the staff in the office and one for the clients, 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. Garage door was locked, and laundry detergent and chemicals were inaccessible to client. There are no pools or large bodies of water. LPA observed broken chairs, broken monitor, broken doors, and water hose are blocking walkway in back yard. All client bedrooms were toured. Each bedroom has a bed, linen, dresser, light, and sufficient closet space. Bathrooms were clean, and the hot water was tested 113.1 F degree, which is within the required 105 - 120 degrees. Trash bins in the bathrooms observed without covers/ lids. The kitchen was inspected. LPA observed that there is not a sufficient 2-day supply perishable and 7-day supply of non-perishable food. Walls and ceiling in the kitchen are dirty, A/C vents are dirty.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: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2024
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 05/16/2024 02:05 PM - It Cannot Be Edited


Created By: Nune Margaryan On 05/16/2024 at 11:38 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: AZUSA HOME
FACILITY NUMBER: 198603128

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2024

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
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Based on observation, the licensee did not comply with the section cited above. Wals / ceiling in the kitchen are dirty, A/C vents are dirty, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2024
Plan of Correction
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Administrator will clean the kitchen walls/ ceiling, A/C vent covers and submit a photo of the area showing that it has been cleaned. The photo will be submitted to LPA by 05/23/2024.
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed that broken chairs, broken monitor, broken doors and water hose are blocking walkway in back yard, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2024
Plan of Correction
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Administrator will remove items and send picture proof of walkway in backyard is free from obstruction to LPA via email by 05/23/2024.
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: 05/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/16/2024 02:05 PM - It Cannot Be Edited


Created By: Nune Margaryan On 05/16/2024 at 11:38 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: AZUSA HOME
FACILITY NUMBER: 198603128

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(f)(1)
Fixtures, Furniture, Equipment, and Supplies
(f) Solid waste shall be stored, located and disposed of in a manner that will not transmit communicable diseases or odors, create a nuisance, or provide a breeding place or food source for insects or rodents. (1) All containers, including movable bins, used for storage of solid wastes shall have tight-fitting covers kept on the containers; shall be in good repair, shall be leakproof and rodent-proof.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above: Trash bins in the bathrooms observed without covers/ lids which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2024
Plan of Correction
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Licensee/Administrator was agree to buy new trash bins for both bathrooms. Pictures will be send to LPA via email by the POC due date.
Type B
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. There was not a sufficient 2 day supply pereshable and 7 day supply of non-perishable foods, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2024
Plan of Correction
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Administrator will ensure that a 2-day supply of perishable and a 7 day supply of nonperishable foods are available for the clients at all times. Administrator will show LPA proof / receipts of grocery shopping for the facility by the POC due date.
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: 05/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024


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: 05/16/2024
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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. Carbon monoxide/smoke detectors in the hallway and in the client rooms are operational. LPA reviewed clients and staff files. LPA confirmed staff working have fingerprint clearances. LPA reviewed clients medications. Medications are documented properly and given as prescribed. Last Fire drill was conducted on 02/02/2024.

Deficiencies are being cited. See LIC 809D.



Exit interview was conducted with Mirna Alderete. A copy of the report/appeal rights was issued.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
LIC809 (FAS) - (06/04)
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