<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603201
Report Date: 10/17/2024
Date Signed: 10/17/2024 10:48:08 AM

Document Has Been Signed on 10/17/2024 10:48 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:HEART TO HOME RESIDENTIAL FACILTYFACILITY NUMBER:
198603201
ADMINISTRATOR/
DIRECTOR:		MINES, JASMINEFACILITY TYPE:
735
ADDRESS:795 E ELIZABETH STTELEPHONE:
(626) 233-0725
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 6CENSUS: 2DATE:
10/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:06 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
11:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) S Vaid conducted an unannounced annual visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to Idalia Guardo and was granted access into the facility. Administrator Jennifer Dollentas, arrived shortly thereafter and assisted with the visit. There are two (2) 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 throughout 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 (3) individual client bedrooms, one shared room, a living room, dining room, a kitchen, staff office, laundry room, two (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 108.7- 109 .6 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. The facility has three (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 six (6) ambulatory clients. Care and supervision to meet the clients’ needs was observed.
Staffing: A total of nine (4) full-time and (5) part time staff members provide care and supervision to the clients. Ratio is 1:1. Continued on 809C.......
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2024
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HEART TO HOME RESIDENTIAL FACILTY
FACILITY NUMBER: 198603201
VISIT DATE: 10/17/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Personnel Records/Staff Training: Administrator’s certificate expired 01/23/2025. 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: Two (2) 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. All appliances observed operational.

Health Related Services: Clients are assisted with self-administration of prescription and non-prescription medications. Two (2) centrally stored resident medication records were reviewed. Centrally stored medications are kept in a safe and locked not accessible to clients in care. Medications are given according to Physician directions.

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 09/30/2024.

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

No deficiencies were noted on today's visit, held exit interview and a copy of this report were provided to Administrator Jennifer Dollentas.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2