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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603265
Report Date: 02/17/2023
Date Signed: 02/17/2023 03:31:34 PM

Document Has Been Signed on 02/17/2023 03:31 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:GHENTFACILITY NUMBER:
198603265
ADMINISTRATOR:MORENO, DAISYFACILITY TYPE:
735
ADDRESS:18423 E. GHENT STTELEPHONE:
(855) 302-3331
CITY:AZUSASTATE: CAZIP CODE:
91702
CAPACITY: 4CENSUS: 4DATE:
02/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:41 PM
MET WITH:Daisy Moreno TIME COMPLETED:
03:46 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPA met Administrator Daisy Moreno and explained the reason for the visit. Physical Plant was toured, sample record of medications was reviewed, and food supply was inspected.

The following was observed/inspected:
· LPA and Administrator/Staff toured the home and inspected (4) client bedrooms, (1) office room, (3) bathrooms, living room, dining room, kitchen, and den area. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the clients located in the back patio. Passageways and exits are free of obstruction. The water temperature was tested in bathroom #1 and bathroom and measured between 117.3 6F – 118.7F which is within the required 105 - 120 degrees. Kitchen water temperature measured 122.9 which is not within range. Client bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have sufficient closet space. Client beds have the required linen, and the linen is in good condition. Smoke detectors are intertwined with carbon monoxide detectors and were observed throughout the facility. There is a fire extinguisher located in the office which is fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked in the office and are inaccessible to clients. Cleaning supplies and toxins are locked in a closet in the office and are inaccessible to clients. First Aid kit was fully stocked with current manual.
· Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
· Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed.
· (3) out of the (4) client medications were reviewed. Medications are centrally stored in the office.
· Staff and Client files were not reviewed during today's visit.
· Wrought iron on window adjacent to front door needs new lock as it is missing.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were deficiencies observed during the visit. See 809D Exit interview held and a copy of the report was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2023
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 3
Document Has Been Signed on 02/17/2023 03:31 PM - It Cannot Be Edited


Created By: Alberto Lopez On 02/17/2023 at 03:15 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: GHENT
FACILITY NUMBER: 198603265

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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. Water in kitchen measured 122.9 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/18/2023
Plan of Correction
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Administrator will adjust water temperture and send proof to LPA by POC date.
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: 02/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/17/2023 03:31 PM - It Cannot Be Edited


Created By: Alberto Lopez On 02/17/2023 at 03:15 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: GHENT
FACILITY NUMBER: 198603265

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2023

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 observation, the licensee did not comply with the section cited above. window lock on wrought iron is missing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/22/2023
Plan of Correction
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Administrator will replace lock on the wrought iron and send photo as proof by POC date.
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: 02/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2023


LIC809 (FAS) - (06/04)
Page: 3 of 3