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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603130
Report Date: 09/07/2023
Date Signed: 09/07/2023 03:58:13 PM

Document Has Been Signed on 09/07/2023 03:58 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MS FAMILY HOME LLCFACILITY NUMBER:
198603130
ADMINISTRATOR:SISON, TESFACILITY TYPE:
735
ADDRESS:13649 E RUSSELL STTELEPHONE:
(562) 945-5425
CITY:WHITTIERSTATE: CAZIP CODE:
90602
CAPACITY: 4CENSUS: 4DATE:
09/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:48 PM
MET WITH:Tes Sison, Administrator TIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Galarza 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 staff Marilyn Ribultan. Administrator Tes Sison arrived shortly after. There are three (3) ambulatory developmentally disabled adults ages 18-59, and one (1) ambulatory resident over the age of 59. The facility is licensed as a level 4e home vendored by Eastern Los Angeles Regional Center. Twelve (12) Adult CARE tool domains were observed and reviewed.

Infection Control:

  • Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility is encouraging hand washing and self symptom check of staff and visitors. An Infection Control Plan and Mitigation Plan were reviewed.

Physical Plant/Environment Safety:
  • The facility is a single story home located in a residential neighborhood licensed for 3 ambulatory and 1 non-ambulatory resident. It consists of 3 resident bedrooms, 1 staff room, 3 bathrooms, dining room, kitchen, living room, family room, outdoor patio, and attached garage.
  • The interior and exterior physical plant was inspected. The fireplace is covered. 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 two (2) fully charged fire extinguishers. Cleaning supplies and toxic substances are inaccessible to clients.
  • Water temperature readings measured between the required 105 - 120 degrees Fahrenheit.
See next page
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2023
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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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: MS FAMILY HOME LLC
FACILITY NUMBER: 198603130
VISIT DATE: 09/07/2023
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Operational Requirements:
  • Fire clearance was approved for one (1) non-ambulatory and three (3) ambulatory residents.
  • Care and supervision to meet the clients needs was observed. No special equipment and supplies are used by clients.
  • Surety bond was reviewed and is current.

Staffing:
  • A total of six (6) staff members provide care and supervision to the clients.

Personnel Records/Staff Training:
  • Administrator certificate expires 10/5/2023.
  • Four (4) 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 and personal rights were reviewed in resident file.

Client Records/Incident Reports:
  • Resident files were reviewed. Documents included are admission agreement, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, IPP reports, personal rights, medical consent, nutritional assessments, Medication Administration Records (MARs), and P & I records.

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 physician orders for modified diets are in place.

See next page.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: MS FAMILY HOME LLC
FACILITY NUMBER: 198603130
VISIT DATE: 09/07/2023
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Health Related Services:
  • Residents are assisted with self administration of prescription and non-prescription medications.
  • Three (3) centrally stored resident medication records were reviewed. Centrally stored medications are kept in a safe and locked place not accessible to resident in care. Medications are given according to Physician directions. 30-Day supply of medications were observed.

Incident Medical and Dental:
  • Residents 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 conducted on 9/3/2023.


Emergency Intervention:
  • No manual restraints or seclusion are used with clients in care.

  • No deficiencies were cited.


Exit interview conducted with Administrator Tes Sison. A copy of the report was issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023
LIC809 (FAS) - (06/04)
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