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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603217
Report Date: 09/30/2023
Date Signed: 09/30/2023 01:30:20 PM

Document Has Been Signed on 09/30/2023 01:30 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:DEL SOL HOME (CARPINTERO)FACILITY NUMBER:
198603217
ADMINISTRATOR:GONZALES, MERCIFACILITY TYPE:
735
ADDRESS:17926 CARPINTERO AVETELEPHONE:
(562) 243-4234
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 4CENSUS: 4DATE:
09/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:36 AM
MET WITH:Merci Gonzales - Licensee/AdministratorTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Katherine Jimenez, Direct Service Professional I (DSPI) and Ralph Cabagnot Direct Service Professional I (DSPI) and explained the purpose of the visit. LPA spoke with the weekend Administrator, Anna Marie Tomilloso on the phone and stated that she will be arriving in the facility. At 10:25am, Administrator Anna Marie Tomilloso arrived. At 10:45am, the Licensee/Administrator Merci Gonzales arrived and assisted LPA with the inspection.The facility is licensed to care for four (4) Developmentally Disabled Adults, ages 18 through 59, non ambulatory only, and has a hospice waiver for 1. All clients residing at this facility receive case management services provided by Harbor Regional Center.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located near the front door. The staff are wearing masks throughout their shift and disposable gloves are used to clean and disinfect the high touched surfaces in the common areas. DSP Ralph Cabagnot did not screen the LPA immediately upon entry, but eventually screened LPA minutes after. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Facility has COVID-19 signage posted throughout the facility. Bathrooms have hand washing signs, soap and paper towels. Staff are adhering to infection control requirements.


Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan and submitted to CCL. Liability Insurance policy in the amount of $1,000,000.00 each occurrence and #3,000,000.00 in the total annual aggregate is valid and will expire on 03/31/2024. A fire clearance for (4) clients is in place. Surety Bond (Summa Insurance Services) is in effect with bond amount of $2000 and expires on 04/24/2027. Fire Drill was last conducted on 09/04/2023 and Earthquake/Emergency Drill on 09/05/2023.
Physical Plant/Environment Safety: The facility is a single storey home located in a residential neighborhood, contains four (4) client bedrooms, two (2) full bathrooms, living room, kitchen, dining area, office area next to the kitchen, backyard, and attached garage. Currently, there are four (4) clients living in the facility. Facility is a Specialized Home. The interior and exterior physical plant was inspected. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, night stand, light, chair and sufficient closet space. Bathrooms have non-skid materials and contained hygiene supplies including liquid soap, paper towels, and toilet paper. Exit doors are free of any obstruction and there are no pools or large bodies of water. LPA observed a small puddle of water in the side yard and Administrator swept it to clear the area. Backyard was inspected and has a shaded area and sitting area. Attached garage was inspected and there is an extra refrigerator/freezer to stock up additional food items. Kitchen knives, sharps objects, are kept in a medium size tool box inside the kitchen cabinet, however there is no lock, which are accessible to clients. The cleaning supplies and toxic substances are stored in a cabinet under the sink which is also kept unlocked and are accessible to clients. The facility has two (2) fireplaces which are both screened and inaccessible to clients. There is one (1) fire extinguisher observed to be fully charged and purchased on 1/15/2023. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. Water temperature's initial readings were not within the required 105-120 degrees Fahrenheit. Administrator adjusted the hot water temperature setting, and the 2nd reading measured 110.4 deg F in bathroom #1, and 114.8 deg F in bathroom #2 which are within Title 22 Regulations requirement.

*****CONTINUED ON LIC809-C******

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2023
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
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: DEL SOL HOME (CARPINTERO)
FACILITY NUMBER: 198603217
VISIT DATE: 09/30/2023
NARRATIVE
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Staffing: A total of seven (7) staff members including the Administrator provide care and supervision to the clients. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility.

Personnel Records/Staff Training: Reviewed files for three (3) staff. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Weekend Administrator certificate expired on 4/02/2023 and submitted renewal to CCL on 3/292/2023. Proof of renewal such as copy of the check and mail receipt were provided to LPA. Licensee/Administrator's certificate expires on 03/26/2024. Both Administrators have HIV training.

Client Rights-Information: Client personal rights are posted. Per Administrator, facility provides internet services to all clients and have access to the facility phone. Administrator also stated none of the clients have their own personal cell phones and (3) out of (4) clients have their own tablets. LPA conducted (1) client interview during the visit as other clients were sleeping.



Client Records-Incident Reports: LPA reviewed Client files for C1 through C3. Client files are maintained at the facility. Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Individual Program Plan (IPP), Behavioral Reports, Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights observed.

Food Service: There are sufficient food supplies of 2-day perishable but insufficient supply of 7-day non-perishable items. Additional food supplies were purchased during the visit. The food is properly stored in the refrigerator (clean and well maintained). There are (2) clients with special diets residing at this facility and the other (2) clients are on g-tubes. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services The medications are centrally stored and in their original containers. Medications were reviewed for C1-C2 to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubbled packed and some are kept in pill bottles.

Incidental Medical Services: Per the Administrator, there is (1) client at this home with incidental medical services and (3) clients have a restricted health condition.

Disaster Preparedness: The facility does have a complete Emergency Disaster and Mass Casualty Plan.

Emergency Intervention: Not-Applicable.

Deficiencies cited on LIC 809D. Exit interview, appeals rights and a copy of this report was provided to the Administrator, Merci Gonzales.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 09/30/2023 01:30 PM - It Cannot Be Edited


Created By: Bennette Pena On 09/30/2023 at 01:06 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: DEL SOL HOME (CARPINTERO)
FACILITY NUMBER: 198603217

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, the licensee did not comply with the section cited above in that kitchen knives, sharps objects, are kept in a medium size tool box inside the kitchen cabinet, however there is no lock, which are accessible to clients. The cleaning supplies and toxic substances are also stored in a cabinet under the sinkkept unlocked and are accessible to clients which poses an immediate health, safety or personal rights risk to clients in care.

POC Due Date: 10/02/2023
Plan of Correction
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The Licensee/Administrator called a service personnel to put locks on the kitchen cabinets were the knives, sharps, cleaning supplies and toxic substances are stored.
***CLEARED during the visit.*****
Type A
Section Cited
CCR
80072(a)(8)(E)1
Personal Rights
1. A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. Bed rails that extend the entire length of the bed are prohibited except for clients who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review, the licensee did not comply with the section cited above in that the Administrator/Licensee cannot provide the physician's orders for half bed rails for (3) out of (4) clients which poses an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 10/02/2023
Plan of Correction
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Licensee/Administrator will ensure that the physician's orders are kept in clients files all the time and will submit the physician's orders to use half bed rails for (3) out of (4) clients to CCL/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:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2023


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 09/30/2023 01:30 PM - It Cannot Be Edited


Created By: Bennette Pena On 09/30/2023 at 01:06 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: DEL SOL HOME (CARPINTERO)
FACILITY NUMBER: 198603217

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 which the water temperature's initial readings were not within the required 105-120 degrees Fahrenheit which poses/posed a potential health, safety or personal rights risk to clientsns in care.
POC Due Date: 10/02/2023
Plan of Correction
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Licensee/Administrator adjusted the hot water temperature setting, and the 2nd reading measured 110.4 deg F in bathroom #1, and 114.8 deg F in bathroom #2 which are within Title 22 Regulations requirement.
****CLEARED during the visit.*****
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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2023


LIC809 (FAS) - (06/04)
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