198603301-8-16-2023-28-AS-CWOG-CUQSCU-20230815134607

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603301
Report Date: 08/15/2023
Date Signed: 08/16/2023 08:36:16 AM

Document Has Been Signed on 08/16/2023 08:36 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:	LAGUARDIA HOME		FACILITY NUMBER:	198603301
ADMINISTRATOR:	CORONADO, TOMASA		FACILITY TYPE:	735
ADDRESS:	18615 LAGUARDIA ST		TELEPHONE:	(626) 581-1384
CITY:	ROWLAND HEIGHTS	STATE: CA	ZIP CODE:	91748
CAPACITY: 4		CENSUS: 4	DATE:	08/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Tomasa Coronado		TIME COMPLETED:	01:55 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 conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met DSP Crystal Coronado 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. 2 Ambulatory and 2 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 and Environmental: The facility is a single story house and located in a residential neighborhood area. The facility includes: living room, dining area, kitchen, closing patio, three clients bedrooms, two clients bathrooms and attached garage. Bedroom#1 and #3 has one bed, one chair, one night stand, one drawer, required furniture and bedding, sufficient lighting and closet space. Bedroom#2 has two beds, one night stand, two drawers, required beddings and furniture and sufficient lighting and closet space. The two clients bathrooms are clean, sanitary and in a good working condition. The hot water temperature tested in two clients bathrooms are between 110.3 and 113.5 degrees F which is within Title 22 regulation. All the appliances in the kitchen and living room are working probably. All the sharp knives and utensils are stored and locked under the sink.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

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: LAGUARDIA HOME	FACILITY NUMBER: 198603301
	VISIT DATE: 08/15/2023

NARRATIVE

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All the cleaning supplies are stored in the locked cabinet in the garage. The passageway, walkway and patio are free of obstruction. At night time, the hallway night will be on for client to access the bathrooms. All the linen are stored in the hallway cabinet and all the extra personal hygiene products are stored in the locked cabinet in the garage. LPA inspected the carbon monoxide detectors and smoke detectors and they are all working well. The facility has a land line telephone system for client to use.

3. Operational Requirements: The facility is approved for 2 ambulatory and 2 non-ambulatory. Currently all clients are ambulatory. The last fire and earthquake drill was conducted on 7/16/23 and 7/17/23. The facility has a covered patio with table and chairs for client to utilized for outdoor activity. The facility would all also let client to attend community activities if there's an opportunity or if client wanted.

4. Staffing: Facility has a sufficient staffing in the facility. There are two staff in AM shift, two to three staff in PM shift and one staff in NOC shift. LPA also reviewed the night shift staff and the staff has the updated training for the facility planned emergency procedure.

5. Personnel Records-Training: All the staff files are stored in the administrator office in another facility. LPA reviewed all staff files are they do have the required documents in their personnel files which includes updated required training hours, first aid certificate, health screening and TB test result. The facility administrator is Tomasa Coronado and her administrator certificate will be expired on 5/19/2024 and her HIV and TB training was dated on 3/18/22.

6. Client's Right-Information : Currently the facility has no client required postural support. The facility does serve adults has internet service shall provide at least one access device.

7. Clients Records-Incident Reports: All clients files are stored and locked in the closet near the entrance area. LPA reviewed all four (4) clients files and all have the required documents which include face sheet, updated physician report, admission agreement, functional capability Assessment, ambulatory status, TB test and medication list.

8. Food Service: The facility has sufficient food supply include minimum two days perishable and seven days non perishable. All the food are stored probably. There's only one client are on restricted low fat diet and for the other clients, staff would chop the food for clients to prevent choking. LPA also checked the refrigerator temperature and its maintained in the required temperature.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

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: LAGUARDIA HOME	FACILITY NUMBER: 198603301
	VISIT DATE: 08/15/2023

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9. Health Related Services: All clients' medication are stored and locked in the kitchen cabinet and they are inaccessible to clients. LPA inspected all four (4) clients medication and their record and they all seemed accurate and up-to-dated.

10. Incident Medical Services: The facility does not have any one with Prohibited Health Condition. Currently facility has one client with restricted health condition. The restricted health condition plan is placed in client's file and its up-to-dated and dated on 11/10/22. Its reviewed by client's primary physician and regional center. And all facility staff are received required training.

11. Disaster Preparedness: The facility has an updated Emergency Disaster Plan (LIC610D) dated on 8/30/2022. The last emergency disaster drill was conducted on 7/16/23 and the facility has two alternative temporary shelter location.

12. Emergency Intervention: All the facility staff has an updated CPI Training and they would follow the protocol and procedures of the facility emergency intervention policy and plan.

No deficiencies were observed during today's visit.

Exit Interview conducted. A copy of the report was provided to the administrator Tomasa Coronado.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

LIC809 (FAS) - (06/04)

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