198603298-8-16-2023-28-AS-CWOG-CULVNF-20230811163504

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603298
Report Date: 08/11/2023
Date Signed: 08/16/2023 08:33:08 AM

Document Has Been Signed on 08/16/2023 08:33 AM - 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:	OTTERBEIN HOME		FACILITY NUMBER:	198603298
ADMINISTRATOR:	CORONADO, TOMASA		FACILITY TYPE:	735
ADDRESS:	2017 OTTERBEIN AVE		TELEPHONE:	(626) 581-9192
CITY:	ROWLAND HEIGHTS	STATE: CA	ZIP CODE:	91748
CAPACITY: 4		CENSUS: 4	DATE:	08/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Tomasa Coronado		TIME COMPLETED:	04:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Christine Wong and Sanjay Vaid conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met DSP Sylvia Ray and explained the reason of the visit and assisted with the visit. Shortly after, the administrator Tomasa Coronado arrived and assisted with the visit. The facility is approved for serve Developmentally Disabled Adults AGE RANGE 18 THROUGH 59. APPROVED FOR (4) AMBULATORY, OF WHICH (2) MAY BE NON-AMBULATORY.. The facility is licensed as a level 4I vendored by San Gabriel Pomona Regional Center. The following twelve (12) tool domains were observed and reviewed: Infection Control, Physical Plant/Environmental Safety, Operational Requirements, Staffing, Personal Records-Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incidental Medical Services, Disaster Preparedness and Emergency Intervention. 1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility still encourages hand washing, mask wearing for staff and self symptom check of staff. The facility has an Infection Control Plan and COVID-19 mitigation plan in place. 2.Physical Plant & Environmental Safety: The facility is a single story house and located in a residential neighborhood area. The facility includes: dining area, kitchen, living room, four clients bedrooms and two clients bathrooms, laundry room/supply area and administrator office. Each client room has one bed, one chair, one drawer, required beddings and furniture and sufficient lighting and closet space. The two bathrooms are clean, sanitary and in a good working condition. The hot water temperature in two bathrooms were tested between 114.9 and 115.1 degrees F which are within Title 22 regulation. The passageway, walkway and patio are free of obstruction. There's an extra linen and towels are stored in the hallway cabinet. (See LIC809C for continuation)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

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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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: OTTERBEIN HOME	FACILITY NUMBER: 198603298
	VISIT DATE: 08/11/2023

NARRATIVE

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All the sharp knives and utensils are locked under the sink. All the chemicals and cleaning supplies are all locked in the laundry room/supply area which are inaccessible to the clients. All the appliances include stove, oven, microwave, refrigerator, washer and dryer are working probably. LPA also inspected the smoke detectors and carbon monoxide detectors and they are all working well. The extra personal hygiene products are also stored in the laundry/supply area. Facility has a telephone services for client to utilize.

3. Operational Requirements: The facility is licensed for APPROVED FOR (4) AMBULATORY, OF WHICH (2) MAY BE NON-AMBULATORY. Currently there are two are non-ambulatory clients in the facility. The last fire/disaster drill was conducted on July 10, 2023. The facility has a backyard patio with table and chairs for client to utilize. Client are allowed to attend or participate community activities if they want to.

4. Staffing: The facility has sufficient staffing. The facility has two staff in AM Shift and two to three staff in PM Shift and one staff in NOC shift. The night shift staff has the required training for facility planned emergency procedure training.

5. Personnel Records Training: All the staff files are stored and maintained in the administrator office. All the staff are over 18 years old and they are all criminal background cleared and associated with the facility. The facility administrator is Tomasa Coronado. She also has updated HIV and TB Training dated on 3/18/22. The staff also have required documents included health screenings, TB Test and updated training requirements include medication management and First aid.

6. Client Rights-Information: The facility does not have any clients with postural support. The facility does serve adults has internet service shall provide at least one access device.

7. Client Records-Incident Reports: All the clients files are stored and maintained in the closet near the living room. All the clients files have required documents including face sheet, admission agreement, Functional Capability Assessment, Individual Program Plan (IPP), Physical report and TB test result, ambulatory status and medication list.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: OTTERBEIN HOME	FACILITY NUMBER: 198603298
	VISIT DATE: 08/11/2023

NARRATIVE

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8. Food Service: There's no client with a modified diet but staff would chop the food for clients to prevent choking. LPA inspected the food in the facility and they do have 2 days perishable and 7 days non-perishable food supply. The food are stored probably in the facility. The refrigerator is maintained in the required temperature.

9. Health Related Services: The client's medication is centrally stored and locked in the kitchen cabinet and is inaccessible to clients. LPA inspected four clients medication and LPA observed Client#1 (C1) medication for Divalproex- 5 capsule 625mg by mouth, 3x day and client was missing one medication on 8/10/23 for bedtime.

10. Incidental Medical Services- Currently the facility does not have any clients with restricted or prohibited health conditions. The first aid kit are stored under the sink and they are locked and inaccessible to clients and it has all the required items.

11. Disaster Preparedness: The facility has an updated emergency disaster plan and its dated on 8/30/22. The facility has two temporary alternative shelter location. The last quarterly fire/emergency drill was completed on 7/10/2023.

12. Emergency Intervention: All the staff has CPI training and its all updated but the CPI is the last resources for the facility and they would use verbal prompt first.

Per Title 22 Regulations, the deficiencies observed are documented on LIC809D.

An exit interview was conducted and a copy of this report and appeal rights provided to Tomasa Coronado.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/16/2023 08:33 AM - It Cannot Be Edited

Created By: Christine Wong On 08/11/2023 at 03:55 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: OTTERBEIN HOME	FACILITY NUMBER: 198603298
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80075(b)(5)(B)

Health-Related Services

(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and LPAs' Observation, LPA reviewed Client#1 (C1) medication and observed C1 was missing the medication of Divalproex for bedtime which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/12/2023
	Plan of Correction
1 2 3 4	Administrator will ensure the medicaiton once ordered by physician the medication is given according to the physician's directions. Administrator will provide the in service training to all staff about medicaiton and send the in service trianing log to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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:

David Sicairos

LICENSING EVALUATOR NAME:

Christine Wong

LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

LIC809 (FAS) - (06/04)

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