198603298-7-12-2024-28-AS-CWOG-D74NTB-20240712104430

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603298
Report Date: 07/12/2024
Date Signed: 07/12/2024 10:45:43 AM

Document Has Been Signed on 07/12/2024 10:45 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/ DIRECTOR:	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:	07/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:16 AM
MET WITH:	Tomasa Coronado		TIME VISIT/ INSPECTION COMPLETED:	10:55 AM

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) Wong conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with DSP Sylvia Ray and explained the reason of the visit and allowed the entry of the facility. Shortly after, the administrator Tomasa Coronado arrived and assisted with the visit. The facility is approved for serve Developmentally Disabled Adults 18-59 years old and fire clearance approved for four ambulatory and which two (2) maybe 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: The facility has an updated infection control plan in place. The facility still practice hand washing and disinfected the facility. Observed the PPE supplies and it's sufficient. 2. Physical Plant/Environmental Safety: The facility is a single story house and located in a residential neighborhood area. The facility includes: living room, kitchen, dining area, four clients bedrooms and two client's bathroom, administrator office and laundry area/storage area. Each client bedrooms has one bed, one chair, one drawer, required beddings and sufficient lighting and closet space. The two client's bathrooms are clean, sanitary and in a good working condition. The hot water temperature in two client's bathroom were tested between 134.9 and 134 degrees which is over the requirement of the Title 22 regulation. All the appliances in the kitchen are working properly. All the sharp knives and utensils are stored and locked under the kitchen sink. The extra personal hygiene products were stored in the cabinet in the laundry area/storage area. The hallway night is on during night time so client can have access to the non-private bathrooms. LPA inspected the carbon monoxide detector is mounted on the wall near the entrance area and it's working well. The facility has a telephone services on the premises.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2024

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

FACILITY NAME: OTTERBEIN HOME	FACILITY NUMBER: 198603298
	VISIT DATE: 07/12/2024

NARRATIVE

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3. Operational Requirements: The facility is approved for four (4) which two may be non-ambulatory. Currently the facility has two non-ambulatory clients. The last fire drill was conducted on 7/3/24. The clients can attend the community events if there's an opportunity. The facility back yard has a shaded area with table and chairs for client to utilize the outdoor activity.

4. Staffing: The facility has sufficient staffing to provide care and supervision to clients. The NOC shift staff has the required Facility Emergency Procedure Training.

5. Personnel Records-Training: All the staff files are stored and locked at Administrator office. All the staff in the facility is over 18 years old, fingerprint cleared and associated with the facility. LPA inspected three staff and administrator files and they all have the required documents in file which included: employee application, health screening with TB Test result, updated First aid Certificate and required training hours. The administrator is Tomasa Coronado and her administrator certificate was expired on 5/19/24 but currently her administrator certificate is pending with CCL system. The administrator has the required HIV and TB Training certificate but just expired on 3/22/24.

6. Client's Right/Information: The facility does not have any client who required any postural support. The facility would provide internet service for client with at least one internet access device with video conferencing technology with their primary doctor, family or day program if needed.

7. Food Service: The facility provides three meals and snacks to client per day. The facility does not have any client required modified diet that's prescribed by doctor but facility would monitor client's diet due to client medical condition and facility would chop all the food for clients for safety hazard. The facility has sufficient two days perishable and seven days non perishable food supply. All the food in the facility are stored properly.

8. Client's Records-Incident reports: All the clients files are stored in the closet near the living room. LPA inspected all four (4) client's file and they all have the required documents included: face sheet, admission agreement, updated physician and dental report and TB test result, medication list, ambulatory status and updated Individual program plan (IPP) and functional capability assessment.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2024

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: 07/12/2024

NARRATIVE

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9. Health Related Services: The facility would arrange with doctor and dental appointments for clients with transportation. All the client's medication are centrally stored and locked in the kitchen medication and under the kitchen sink. LPA inspected all four client's medication and they all seemed updated and accurate. LPA also inspected the first aid kit and they are stored and locked under the kitchen sink and they have all the required supplies in the kit.

10. Incidental Medical Services: Currently there's no client with any restricted health condition or prohibited health condition.

11. Disaster Preparedness: The facility has an updated Emergency Disaster Plan in place (LIC610D) and the last disaster drill was conducted on 7/3/24 and the facility has two alterative temporary shelter location if there's an emergency.

12. Emergency Intervention: Facility does not use any restraint on clients but all staff are trained by CPI with an updated certificate in file.

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: 07/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/12/2024 10:45 AM - It Cannot Be Edited

Created By: Christine Wong On 07/12/2024 at 10:26 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: 07/12/2024

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
1 2 3 4	Based on observation, LPA checked the hot water in two client's bathroom and they were tested between 134.9 and 134 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/13/2024
	Plan of Correction
1 2 3 4	The administrator will fix the hot water heater immediately and will measure and send the facility hot water log for seven days to LPA by 7/19/24

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: 07/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2024

LIC809 (FAS) - (06/04)

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