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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603201
Report Date: 10/10/2023
Date Signed: 10/10/2023 01:11:58 PM

Document Has Been Signed on 10/10/2023 01:11 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: 4DATE:
10/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:37 AM
MET WITH:Sean Estrella, Administrator TIME COMPLETED:
01:19 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez 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 Kenia Williams and was granted access into the facility. Administrator Sean Estrella arrived shortly thereafter and assisted with the visit. There are one (4) ambulatory developmentally disabled clients who reside in the home. The facility is vendored through Frank D Lanterman Regional Center.

The following was observed:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. Facility still screens visitors and are disinfecting through out the day.

Physical Plant/Environment Safety: The facility is a single-story home located in a residential neighborhood that is licensed for a capacity of six (6) ambulatory developmentally disabled clients between the ages of 18-59, It consists of three (2) individual client bedrooms, one shared room, a living room, dining room, a kitchen, staff office, laundry room (2) shared client bathrooms, a front and back patio area, and a detached garage which serves as a storage area for the facility. Hot water temperature measured at 106.3 - 109.7 Degrees which is within range of 105-120 Degrees F. 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. Fire alarm system is operational. There is a cover made of wood for the crawl space that is need of replacement as it has a hole, is falling apart and poses a danger to clients in care. The facility has four (3) fully charged fire extinguishers that are kept at the facility and one in the garage. Cleaning supplies and toxic substances are inaccessible to clients.


Operational Requirements: The Program Design was reviewed. Fire clearance was approved by LA County Fire Department for three (6) ambulatory clients. Care and supervision to meet the clients’ needs was observed.
Staffing: : A total of nine (6) full-time and 3 part time staff members provide care and supervision to the clients
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2023
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 5
Document Has Been Signed on 10/10/2023 01:11 PM - It Cannot Be Edited


Created By: Alberto Lopez On 10/10/2023 at 12:24 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: HEART TO HOME RESIDENTIAL FACILTY
FACILITY NUMBER: 198603201

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above. One cream Ketoconazole 2% for C1 was brand new, full and had not been used today but was mark as given. Staff1 Admitted to checking off MAR in error which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/11/2023
Plan of Correction
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Administrator will train staff on administration of medication and send proof to LPA by POC date.
Type A
Section Cited
CCR
80075(b)(6)(C)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (6) If the client is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (C) The date and time the PRN medication was taken, the dosage taken, and the client's response, shall be documented and maintained in the client's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above. One PRN promethazine was 3/4 empty and only one dose for 5mm was documented poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/11/2023
Plan of Correction
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Administrator will train staff on documentation of medication and send proof to LPA by POC 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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2023


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 10/10/2023 01:11 PM - It Cannot Be Edited


Created By: Alberto Lopez On 10/10/2023 at 12:24 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: HEART TO HOME RESIDENTIAL FACILTY
FACILITY NUMBER: 198603201

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2023

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 interview, the licensee did not comply with the section cited above There is a cover made of wood on the crawl space on the side of the house that is in need of replacement which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/10/2023
Plan of Correction
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Administrator will replace the cover on the crawl space and send proof to LPA by POC date. In the meantime Administrator will make that area inaccessible to client in care.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2023


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: HEART TO HOME RESIDENTIAL FACILTY
FACILITY NUMBER: 198603201
VISIT DATE: 10/10/2023
NARRATIVE
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Personnel Records/Staff Training: Administrator’s certificate expired 05/08/2023 and renewal is pending. 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: Personal rights are posted near the entrance and in every client room.

Client Records/Incident Reports: Four (4) client files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, nutritional assessments, medication records, and P & I money were reviewed.

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: Clients are assisted with self-administration of prescription and non-prescription medications. Four (4) centrally stored resident medication records were reviewed. Centrally stored medications are kept in a safe and locked not accessible to clients in care. Most medications are given according to Physician directions. One PRN was never used, and another was never recorded according to regulations.

Incident Medical and Dental: All clients 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 but needs to be update. An emergency drill was last documented on 8/02/2023.

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. Exit interview held and a copy of the report along with appeal rights were provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023
LIC809 (FAS) - (06/04)
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