198603301-7-12-2024-28-AS-CWOG-D74RRF-20240712131503

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603301
Report Date: 07/12/2024
Date Signed: 07/12/2024 01:15:42 PM

Document Has Been Signed on 07/12/2024 01:15 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	LAGUARDIA HOME		FACILITY NUMBER:	198603301
ADMINISTRATOR/ DIRECTOR:	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:	07/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:13 AM
MET WITH:			TIME VISIT/ INSPECTION COMPLETED:	01:30 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 with DSP Crystal Coronado and the administrator Tomasa Coronado and they both assisted LPA 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: Facility has an updated infection control plan in place. The facility staff continues to practice hand washing with clients and disinfect the facility. Observed 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: kitchen, dining area, living room, three client's bedrooms, two client's bathrooms, patio area and an attached garage with laundry area. Bedroom#1 and #3 has one bed, one drawer, one night stand, required bedding and furniture and sufficient lighting and close space. Bedroom#2 has two beds, one nigh stand, two drawers, and required bedding and furniture 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 bathrooms are tested 109.4 and 117.6 degrees F which is with the Title 22 regulation. All the kitchen appliances are working properly. The sharp knives and utensils are stored and locked in the cabinet in the garage and inaccessible to clients. All the chemicals and cleaning supplies are also stored and locked in the cabinet in the garage. All the extra personal hygiene products are stored in the cabinet in the garage too. There's a night light in the hallway for client to access the non-private bathrooms. LPA inspected the carbon monoxide detector and it's mounted on the wall and near the Television in the Living room and it's working well. The facility has a telephone services in 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)

Page: 1 of 3

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: 07/12/2024

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
26
27
28
29
30
31
32

3. Operational Requirements: The facility is licensed for two ambulatory and two non-ambulatory. Currently all clients in the facility are ambulatory which is within the fire clearance requirements. The last fire drill was conducted on 7/3/24 and facility does monthly fire drill with clients and staff participation. The clients is able to attend the community events if there's an opportunity or chance. The facility has a back yard with shaded area with table and chairs for client to utilize the outdoor activity.

4. Staffing: The facility has sufficient staffing in the facility to provide care and supervision to clients. The NOC shift staff has the required facility emergency procedure training.

5. Personnel Record-Training:All the staff files are kept with the administrator and all staff in the facility are over 18 years old, fingerprint cleared and associated with the facility. LPA inspected two staff and administrator file. They all have the required documents in file which include: employee application, health screening with TB Test result, updated first aid certificate and required training hours. The facility administrator is Tomasa Coronado and her administrator certificate was expired on 5/19/24 but currently her administrator renew package is pending with the CCL system since 5/20/24 and Administrator's HIV and TB training certificate was just expired on 3/22/24.

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

7. Food Service: The facility provide three meals and snacks to client per day. There's no client required any modified diet that's prescribed with the doctor but facility would monitor client's diet due to client's medical condition. 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 client's files are stored the closet near the entrance area. All clients have the required documents in file which included: face sheet, admission agreement, functional capacity assessment, medication list, ambulatory status, updated physician report with TB test result and updated Individual Program Plan. LPA also reviewed client's P&I monies and all the money and receipts and balance are updated and accurate.

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)

Page: 2 of 3

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: 07/12/2024

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
26
27
28
29
30
31
32

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

10. Incidental Medical Services: Currently the facility has one client who is under the restricted health condition. LPA inspected client's files and it has all the required documents which is included: updated restricted health condition care plan signed by the client's primary physician and regional center representative and facility representative on 1/22/24 and updated staff training dated on 2/21/24. Facility does not have any client who is with prohibited health condition.

11. Disaster Preparedness: The facility has an updated LIC 610D Emergency Disaster Plan in file. The last fire/disaster/Earthquake drill was conducted on 7/3/24. The facility also has an two temporary alternative shelter location available in case there's an emergency.

12. Emergency Intervention: The facility does not use any restraint on clients but they do use CPI for client and they would follow the protocol for CPI requirements and all staff have the updated CPI training certification.

No deficiencies were observed during the annual inspection.

Exit Interview conducted. The copy of the report was provided to the administrator 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)

Page: 3 of 3