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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603265
Report Date: 11/19/2024
Date Signed: 11/19/2024 02:15:41 PM

Document Has Been Signed on 11/19/2024 02:15 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:GHENTFACILITY NUMBER:
198603265
ADMINISTRATOR/
DIRECTOR:		BALLINGER ASHLEY D.FACILITY TYPE:
735
ADDRESS:18423 E. GHENT STTELEPHONE:
(626) 430-6101
CITY:AZUSASTATE: CAZIP CODE:
91702
CAPACITY: 4CENSUS: 4DATE:
11/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Ashley Ballinger, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Mayra Cota and Nune Margaryan conducted and unannounced annual visit using the Care Inspection Evaluation Tool (CARE). LPAs met with Chelsea Harmon, Direct Support Staff and Administrator Ashley Ballinger arrived thereafter and assisted with the visit and the tour of the facility. Reason for the visit was explained. The physical plant was inspected along with client and staff records, medication and food supply. The facility is licensed to serve developmentally disabled clients between the ages of 18 to 59 and receive services from San Gabriel/Pomona Regional Center. Two (2) clients were attending day program and two (2) clients were present at the facility at the time of visit. The facility is a single home, and it is located within a residential neighborhood. LPAs and Administrator toured the home and inspected the following: four (4) client bedrooms, one (1) office, three (3) bathrooms, living room, kitchen, dining area and den. The outdoor environment which consists of a front and backyard was observed to be well maintained and there are no pools or large bodies of water. A shaded area located in the back patio is available and accessible for the clients. Laundry area which has a washer and dryer is in the backyard under a covered area. Passageways and exits are free of obstruction. However, during today's visit LPAs observed gardening tools in the patio area such as a rake and metal watering wand were unlocked and accessible to clients. The water temperature was tested in bathrooms #1-3 and kitchen and measured between 108.6F - 114 F which is within the required regulations 105 - 120 degrees. 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 are two (2) fire extinguisher located in the office and in the kitchen and were fully charged. The kitchen was observed for the ability to prepare and serve food.

Cont. 809C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mayra Cota
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
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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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: 11/19/2024
NARRATIVE
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Appliances in the kitchen were functional but not clean. The stove was observed to be dirty with oil stains. Kitchen cabinets also needed cleaning. LPAs observed during the tour there was not enough non-perishable food for 7 days. 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. 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. Last fire drill was conducted on 9/30/2024.

Deficiencies are being cited. See LIC 809D.

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

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mayra Cota
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/19/2024 02:15 PM - It Cannot Be Edited


Created By: Mayra Cota On 11/19/2024 at 01:04 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: 11/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Buildings and Grounds. 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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Based on observation, the licensee did not comply with the section cited above. During today's visit LPAs observed gardening tools in the patio area such as a rake and metal watering wand were unlocked and accessible to clients,
which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2024
Plan of Correction
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2
3
4
Gardening tools were locked immediately. No further actions needed.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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4
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:Mayra Cota
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 11/19/2024 02:15 PM - It Cannot Be Edited


Created By: Mayra Cota On 11/19/2024 at 01:15 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: 11/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85076(d)(1)
Food Service. The licensee shall meet the following food supply and storage requirements:
(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
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Based on observation, the licensee did not comply with the section cited above. LPAs observed during the tour there was not enough non-perishable food for 7 days which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2024
Plan of Correction
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Administrator purchesed non-perishable food for 7 days at the time of visit
Type B
Section Cited
CCR
80087(a)
Buildings and Grounds. 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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4
Based on observation, the licensee did not comply with the section cited above. The stove was observed to be dirty with oil stains. Kitchen cabinets also needed cleaning. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2024
Plan of Correction
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2
3
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Stove and kitchen cabinets were cleaned by staff at the time of visit. No further actions needed.
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:Mayra Cota
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2024


LIC809 (FAS) - (06/04)
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