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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603298
Report Date: 08/16/2021
Date Signed: 08/16/2021 12:18:15 PM

Document Has Been Signed on 08/16/2021 12:18 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:OTTERBEIN HOMEFACILITY NUMBER:
198603298
ADMINISTRATOR:CORONADO, TOMASAFACILITY TYPE:
735
ADDRESS:2017 OTTERBEIN AVETELEPHONE:
(626) 581-9192
CITY:ROWLAND HEIGHTSSTATE: CAZIP CODE:
91748
CAPACITY: 4CENSUS: 4DATE:
08/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Tomasa Coronado (Administrator)TIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kruz Long conducted a site visit for the annual inspection. Upon arriving at the facility LPA met with Administrator Tomasa Coronado and explained the purpose of the visit. The facility is licensed to serve age range 18 through 59. Approved for (4) Ambulatory, of which (2) may be Non-Ambulatory.

The facility is located in a residential area. A tour of the single-story facility includes: Living room, attached garage/office/laundry room, kitchen/dining room, 4 client bedrooms and 2 bathrooms.

During today’s visit, LPA observed the following: Licensee is not operating beyond the conditions and limitations specified on the license, including the capacity. All clients are protected against hazards. All outdoor and indoor passageways are free of obstruction. There are no pools or large bodies of water on the premises. There are no firearms on the premises and other dangerous weapons such as knives are locked in the kitchen cabinet. Disinfectants, cleaning solutions, poisons are inaccessible to clients. A comfortable temperature for clients is maintained. Fire extinguisher mounted to the dining room wall is fully charged. Smoke detectors and carbon monoxide detectors are operable. Lamps or lights in all rooms to ensure the comfort and safety were observed. All toilets, hand washing and bathing facilities is safe, sanitary and in operating condition. Hygiene products are readily available. All foods are selected, stored, prepared and served in a safe and healthful manner. Nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days were observed. Freezers and refrigerators are clean, and maintain temperatures. Sufficient staff as necessary to ensure provision of care and supervision to meet client needs were observed. All staff have a criminal record clearance. Staff responsible for direct care and supervision have current first aid. Clients list of their Personal Rights were observed. LPA was allowed to enter the facility to conduct the inspection. The administrator is on the premises a sufficient number of hours necessary to adequately administer the facility in compliance with applicable law and regulation. Continue to LIC809C...
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2021
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: OTTERBEIN HOME
FACILITY NUMBER: 198603298
VISIT DATE: 08/16/2021
NARRATIVE
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 All medications are labeled and maintained in compliance. Medications are safe, locked and inaccessible. The garage has been converted into an office space which was noted during the Pre-licensing inspection and already existed at time of property purchase by the Licensee. Fire safety clearance was also granted based on the existing office in the garage. Water temperature measured at 85.2 degrees F in the bathroom which is connected to the Non-ambulatory client bedroom. LPA observed a hole in the living room wall measuring approximately 4 inches by 8 inches, hole in the wall in the dining area measuring approximately 6 inches by 12 inches, cracked wall under the dining room outlet and a hole in client bedroom #2's door measuring approximately 4 inches by 4 inches.

Per Title 22 Regulations, the deficiencies observed are documented on LIC809D. Failure to correct the deficiencies may result in civil penalties.

An exit interview was conducted and a copy of this report and appeal rights provided to Tomasa Coronado.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/16/2021 12:18 PM - It Cannot Be Edited


Created By: Kruz Long On 08/16/2021 at 11:41 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: OTTERBEIN HOME
FACILITY NUMBER: 198603298

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/17/2021
Section Cited

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800889(e)(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:
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 Water temperature measured at 85.2 degrees F in the bathroom which is connected to the Non-ambulatory client bedroom.
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Type B
08/27/2021
Section Cited

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80087(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: LPA observed a hole in the living room wall measuring approximately 4 inches by 8 inches, hole in the wall in the dining area measuring approximately
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6 inches by 12 inches, cracked wall under the dining room outlet and a hole in client bedroom #2's door measuring approximately 4 inches by 4 inches.
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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:Fernando Fierros
LICENSING EVALUATOR NAME:Kruz Long
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2021


LIC809 (FAS) - (06/04)
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