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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603180
Report Date: 09/05/2023
Date Signed: 09/05/2023 03:27:53 PM

Document Has Been Signed on 09/05/2023 03:27 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:RAECHELLE CARE HOMEFACILITY NUMBER:
198603180
ADMINISTRATOR:BERG, TIAFACILITY TYPE:
735
ADDRESS:2215 W 15TH STTELEPHONE:
(323) 656-8266
CITY:LOS ANGELESSTATE: CAZIP CODE:
90006
CAPACITY: 30CENSUS: 30DATE:
09/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Martin Espinoza - Med TechTIME COMPLETED:
03:30 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 Martin Espinoza who is a Med Tech at the facility and was granted access into the facility. Administrator Tia Berg arrived shortly thereafter. There are thirty (30) ambulatory mentally disabled clients who reside in the home.

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. LPA asked assistant administrator to send a completed infection control plan to LPA within 7 days.


Physical Plant/Environment Safety:

· The facility is a two-story home located in a residential neighborhood that is licensed for a capacity of thirty (30) mentally disabled clients between the ages of 18-59. It consists of eighteen (18) shared client bedrooms, a living room/dining room, a kitchen, four (4) shared client bathrooms of which Restroom #1’s hot water temperature measured at 105.7 Degrees F, Restroom #2 measured at 109.4 Degrees F, Restroom #3 measured at 107.8 Degrees F, and Restroom #4 measured at 106.8 Degrees F, a front and back patio area, and a laundry area which also contained the facility's chemicals and cleaning solutions.


· The interior and exterior physical plant was inspected. There was a lack of window screens in bedroom #4, and bedroom #2 had a broken drawer.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2023
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 6
Document Has Been Signed on 09/05/2023 03:27 PM - It Cannot Be Edited


Created By: Erik Zaragoza On 09/05/2023 at 02:26 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: RAECHELLE CARE HOME
FACILITY NUMBER: 198603180

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85009(a)
Posting of a License
(a) In facilities with a licensed capacity of seven or more, the license shall be posted in a prominent, publicly accessible location in the facility.

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 in thirty (30) out of thirty (30) clients, as her administrator's certificate was not posted in a prominent, publicly accessible location in the facility, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
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Administrator is to ensure that she will keep her administrator's certificate posted in a prominent location within the facility at all times. Administrator is to send photographic proof that her updated administrator's certificate is posted in the facility by the POC due date.
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 in one (1) out of thirty (30) clients, as the drawer in bedroom #2 had broken handles on it and missing drawers, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
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Administrator is to ensure that the furniture within the resident's rooms is to remain in good repair at all times. Administrator will send photographic proof that the drawer has been fixed to LPA 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:David Sicairos
LICENSING EVALUATOR NAME:Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2023


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 09/05/2023 03:27 PM - It Cannot Be Edited


Created By: Erik Zaragoza On 09/05/2023 at 02:26 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: RAECHELLE CARE HOME
FACILITY NUMBER: 198603180

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

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 in one (1) out of thirty (30) clients, as the windows in bedroom #4 do not have any window screens, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
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Administrator is to ensure that all client bedrooms in the facility will have window screens on them. Administrator is to send photographic proof to LPA by POC due date that window screens have been added to the windows within the room.
Type B
Section Cited
CCR
80066(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in five (5) out of five (5) staff records that were reviewed, as they did not contain the physician's reports, TB Clearance, nor training for any of the staff members of the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
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Administrator is to ensure that all the staff records will be available at the facility to review moving forward. Administrator will email LPA the full staff files 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:David Sicairos
LICENSING EVALUATOR NAME:Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2023


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 09/05/2023 03:27 PM - It Cannot Be Edited


Created By: Erik Zaragoza On 09/05/2023 at 02:26 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: RAECHELLE CARE HOME
FACILITY NUMBER: 198603180

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(d)
Client Records
(d) All client records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in three (3) out of five (5) clients, as they three clients files were missing their medical assessment, appraisal needs and service plan, and Tuberculosis clearance, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/22/2023
Plan of Correction
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Administrator is to ensure that all client files will be kept on the facility's premesis at all times for review. Administrator will email LPA the requested documents by the POC due date.
Type B
Section Cited
CCR
80061(b)(1)(E)
(b) Upon the occurance, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) shall be submitted to the licensing agency within seven days following the occurance of such event. (1) Events reported shall include the following: (E) Any unusual incident or client absence which threatens the physican or emotional health or safety of any client.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based onobservation and record review, the licensee did not comply with the section cited above in one (1) out of thierty (30) clients, as an unusual incident report was not submitted to licensing following a client going AWOL from the facility, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2023
Plan of Correction
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Administrator is to ensure that she will submit all unusual incident reports to licensing by fax when such incidents occur. Administrator will submit the Unusual Incident Report to LPA by 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:David Sicairos
LICENSING EVALUATOR NAME:Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2023


LIC809 (FAS) - (06/04)
Page: 4 of 6
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: RAECHELLE CARE HOME
FACILITY NUMBER: 198603180
VISIT DATE: 09/05/2023
NARRATIVE
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Exit doors are free of any obstruction and there are no pools or large bodies of water. Fire alarm system is operational. The facility has three (3) fully charged fire extinguishers that are kept in the kitchen of the facility as well as in the upper main hallway and bottom main hallway of the facility. Cleaning supplies and toxic substances are inaccessible to clients in a locked storage closet in the backyard of the facility.
· 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 thirty (30) ambulatory clients.


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

· A total of five (5) full-time staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

· Administrator’s certificate is active however she does not have a current certificate on file and it was not posted in a prominent position within the facility.


· Five (5) staff files were reviewed for criminal background clearance and training.
· Personnel records did not have health/TB screenings, CPI training, certifications, and 1st Aid/CPR training.
Client Rights/Information:

· Physician orders were reviewed in client files, and three (3) out of five (5) were not available.

Client Records/Incident Reports:

· Five (5) client files were reviewed and they all contained an admission agreements, however three (3) out of five (5) did not have a Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, nutritional assessments, nor P & I records. One of the clients has gone absent without leave (AWOL) from the facility on 8/15/2023 and this incident was not reported to licensing.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023
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: RAECHELLE CARE HOME
FACILITY NUMBER: 198603180
VISIT DATE: 09/05/2023
NARRATIVE
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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.

· Five (5) 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:

· Three (3) out of five (5) clients did not have a Needs and Services Plan.

· Staff training was not on file.

Disaster Preparedness, and Emergency Intervention:

· A posted Emergency Disaster Plan LIC610D containing emergency evacuation information was observed.

· An emergency drill was last documented on 9/1/2023.



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, the deficiencies observed during the visit are documented on the LIC809D pages. Exit interview held and a copy of the report along with appeal rights were provided.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023
LIC809 (FAS) - (06/04)
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