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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603201
Report Date: 02/09/2023
Date Signed: 02/09/2023 12:44:37 PM

Document Has Been Signed on 02/09/2023 12:44 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:HEART TO HOME RESIDENTIAL FACILTYFACILITY NUMBER:
198603201
ADMINISTRATOR:MINES, JASMINEFACILITY TYPE:
735
ADDRESS:795 E ELIZABETH STTELEPHONE:
(626) 233-0725
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 6CENSUS: 3DATE:
02/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:29 AM
MET WITH:Kenia Williams, House ManagerTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced annual inspection focusing on the Infection Control Domain. LPA was allowed entry into this home by Kenia Williams, House Manager and discussed the purpose of today's visit. The facility cares for Adult Residential and is licensed to have six (6) Ambulatory only, age range 18-59 years old. Facility is vendorized by Frank D. Lanterman Regional Center and currently have three (3) clients in care. LPA observed the facility plant, COVID-19 procedures, reviewed clients' medications and observed food supply. This single-story home contains three (3) bedrooms, two (2) bathrooms, office, living room, kitchen, dining area, backyard, and detached garage.

The following was observed/inspected:
  • The facility had a universal entrance screening area set on the porch including a thermometer, PPE supplies, screening logs, and sign-in sheet.
  • COVID-19 signage was placed in several areas of the facility including bathrooms.
  • Staff wore face masks throughout their shift.
  • Facility maintained a 30-day supply of PPE located in the shed storage outside. Supplies are sufficient.
  • The kitchen was inspected. There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. All the appliances are clean and are working properly.
  • The laundry is located next to the kitchen and has cleaning supplies locked in the upper cabinet inaccessible to clients.
  • Cleaning solutions and sharps were locked and inaccessible.
  • Hot water temperature was measured in the kitchen and (2) bathrooms. Kitchen's hot water temperature read 114.3 deg F, bathroom #1 read 113.9 deg F and bathroom #2 read 110.9 deg F which are all within the required 105 - 120 degrees.
  • Clients bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, night stand, light, chair and sufficient closet space.
  • Bathrooms have the required grabs bars, non-skid materials and contained hygiene supplies including liquid soap, paper towels, and toilet paper.
  • Medications were locked, centrally stored, and given as prescribed. Medications were reviewed for all (3) clients and confirmed that medication is given as prescribed and is documented properly.
  • The common areas such as activity room and dining room are clean and have the required furniture. Furniture and group activities were spaced to encourage physical distancing.
  • The backyard is clean and free of debris. The detached garage has been designated as the activity area and visitor area during the COVID-19 pandemic.
  • There are fire extinguishers in the hallways and kitchen and observed to be fully charged and last serviced in Nov. 2022.
  • There are cameras without audio in the living room, kitchen, front door and dining area. There were no cameras seen in private areas.
  • Smoke detectors/carbon monoxide detectors were present and operable.
  • Clients and staff files were not reviewed during the visit.

There were no deficiencies cited at this time. An exit interview was conducted, and a copy of this report and appeal rights were provided to the House Manager, Kenia Williams.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2023
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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