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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603130
Report Date: 09/26/2024
Date Signed: 09/26/2024 03:34:53 PM

Document Has Been Signed on 09/26/2024 03:34 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/
DIRECTOR:		SISON, TESFACILITY TYPE:
735
ADDRESS:13649 E RUSSELL STTELEPHONE:
(562) 945-5425
CITY:WHITTIERSTATE: CAZIP CODE:
90602
CAPACITY: 4CENSUS: 4DATE:
09/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:55 PM
MET WITH:Tes Sison, Administrator TIME VISIT/
INSPECTION COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Noemi Galarza made an unannounced Required - 1 year annual inspection visit. The purpose of the visit was explained to DSP Merly Tuzon. The facility is licensed as a level 4E Adult Residential Facility (ARF) that serves developmentally disabled residents under age 59, and is vendored by Eastern Los Angeles Regional Center. The facility is a single story home located in a residential neighborhood. It consists of 3 resident bedrooms, 1 staff room, 3 bathrooms, dining room, kitchen, living room, family room, outdoor patio, and attached garage. The following 12 (CARE) tool domains were utilized during the inspection.

Infection Control: The facility has an Infection Control Plan on-site.

Physical Plant/Environment Safety: 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 were tested and are operational. The facility has a fire pull-alarm alert system and one (1) fully charged fire extinguishers. Hot water temperature readings measured between the required 105 - 120 degrees Fahrenheit. Storage areas for cleaning solutions/toxins, knives, and hazardous items were inaccessible to clients.

Operational Requirements: Fire clearance is approved for three (3) ambulatory and one (1) non-ambulatory resident. Care and supervision to meet the clients needs was observed. Special equipment and supplies are used by clients. Facility manages residents P & I monies. Facility has a current Surety Bond that expires 2/12/2027.



Staffing: A total of 5 staff members provide care and supervision to the clients.

Personnel Records/Staff Training: Four (4) staff files were reviewed. Criminal background clearance, continuing education of DSP training, 1st Aid/CPR training, CPI emergency intervention training, and health screening/TB clearance documents were observed/reviewed.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2024
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 2
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: 09/26/2024
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Resident Rights/Information: Resident Personal Rights poster is posted. Internet access is available for residents. Physician's orders are on file. No residents require a modified diet.

Resident Records/Incident Reports: Four (4) resident files were reviewed containing admission agreements, Physician's Reports, IPPs, IEP, medical/functional assessments, TB clearance, personal rights, medical consent, medication records, 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.

Health Related Services: Residents are assisted with self administration of prescription and non-prescription medications. Medications 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. 30-Day supply of medications were reviewed.

Incident Medical and Dental: Files have Needs and Services Plan and updated medical assessments, and COVID-19 vaccination cards on file. Staff training was reviewed.

Disaster Preparedness, and Emergency Intervention: LIC 610D "Emergency Disaster Plan/Disaster and Mass Casualty Plan" is posted.

The last Fire/Emergency Drill was conducted on 9/10/2024, within 6 months of Title 22 requirement.

Emergency Intervention: Facility utilizes CPI emergency intervention technique.

No deficiencies were observed.



Exit interview was conducted with Interim Administrator Tes Sison. Due to printing issues a copy of the report was issued electronically.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC809 (FAS) - (06/04)
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