198603265-12-19-2023-28-AS-SVAD-CYNSY5-20231219131659

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603265
Report Date: 12/19/2023
Date Signed: 12/19/2023 01:17:12 PM

Document Has Been Signed on 12/19/2023 01:17 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	GHENT		FACILITY NUMBER:	198603265
ADMINISTRATOR:	MORENO, DAISY		FACILITY TYPE:	735
ADDRESS:	18423 E. GHENT ST		TELEPHONE:	(626) 430-6101
CITY:	AZUSA	STATE: CA	ZIP CODE:	91702
CAPACITY: 4		CENSUS: 4	DATE:	12/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Alexander Fernandez		TIME COMPLETED:	01:30 PM

NARRATIVE

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Licensing Program Analyst (LPAs) Sanjay Vaid and Nune Margaryan conducted an unannounced annual visit using the Care Inspection Evaluation Tool. LPAs met staff Alexander Fernandez, shortly after Administrator Daisy Moreno arrived and assisted with the visit. Reason for the visit was explained. The physical plant was inspected along with COVID-19 procedures, medications, food supply, and clients and staff records. Facility submitted infection control plan to CDSS. The facility is licensed to serve developmentally disable clients between the ages 18 to 59 and receive services from San Gabriel /Pomona regional Center. One(1) client was at day program and three(3) clients were present at facility.

LPAs and Administrator 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. Laundry washer/dryer is observed located in backyard under covered area. Passageways and exits are free of obstruction. The water temperature was tested in bathroom #1 and bathroom #2 and bathroom #3 measured between 108.6F - 113F which is within the required regulations 105 - 120 degrees. LPAs observed that trash bins in clients bathrooms without covers/lids. 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 and were tested and operable during the visit. 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. LPAs observed during the tour there was not enough food supply 2-day perishable and 7-day non-perishable. 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.

Cont. 809C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

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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Document Has Been Signed on 12/19/2023 01:17 PM - It Cannot Be Edited

Created By: Sanjay Vaid On 12/19/2023 at 11:27 AM

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: 12/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80088(f)(1)

Fixtures, Furniture, Equipment, and Supplies

(f) Solid waste shall be stored, located and disposed of in a manner that will not transmit communicable diseases or odors, create a nuisance, or provide a breeding place or food source for insects or rodents. (1) All containers, including movable bins, used for storage of solid wastes shall have tight-fitting covers kept on the containers; shall be in good repair, shall be leakproof and rodent-proof. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in, Trash bins in clients bathrooms observed without covers/lids which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/19/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator replaced the trashbin at time of visit. Citation was cleared at time of visit. No further action needed.

Type B

Section Cited

CCR

85076(d)(1)

Food Service

(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in, during the tour LPAs observed there was not enough food supply 2-day perishable and 7-day non-perishable which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/22/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator will sent copy of grocery receipt and picture of food supply bought.

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:

Wei Siew Ho

LICENSING EVALUATOR NAME:

Sanjay Vaid

LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GHENT	FACILITY NUMBER: 198603265
	VISIT DATE: 12/19/2023

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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. Medications are centrally stored and locked in the office. Medications are documented properly and given as prescribed. 2 Staff and 4 Client files were reviewed during today's visit. Staff working at facility have fingerprint clearances.

Deficiencies are being cited. See LIC 809D.

Exit interview was conducted with Administrator Daisy Moreno. A copy of the report, appeal rights was issued.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

LIC809 (FAS) - (06/04)

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