198603303-8-16-2023-28-AS-CWOG-CUQV3G-20230815160443

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603303
Report Date: 08/15/2023
Date Signed: 08/16/2023 08:39:19 AM

Document Has Been Signed on 08/16/2023 08:39 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:	PASO REAL HOME		FACILITY NUMBER:	198603303
ADMINISTRATOR:	GLICKMAN, PAMELA		FACILITY TYPE:	735
ADDRESS:	1918 PASO REAL AVE		TELEPHONE:	(626) 810-1945
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:	02:00 PM
MET WITH:	Tomasa Coronado		TIME COMPLETED:	04:20 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 the administrator Tomasa Coronado and explained the reason of the visit and assisted with the visit. The facility is approved for serve Developmentally Disabled Adults AGE RANGE 18 THROUGH 59 and approved for four (4) non-ambulatory only. The facility is licensed as a level 4 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, two clients rooms, two clients bathrooms, supply room, staff office and an attached garage. Each client's bedroom has two beds, drawer(s), required bedding and furniture, sufficient lighting and closet space. The two clients bathrooms are clean, sanitary and in a good working condition. The two client bathroom hot water temperature was tested at 107.0 Degrees F which is within the Tittle 22 regulation. All the appliances in the kitchen and living room are working probably. The sharp knives and utensils are stored and locked under the sink. All the cleaning supplies and chemicals are stored in the shelf and locked in the garage. At night time, the hallway light will be on for client to access to the bathroom. The facility has a land line telephone system. The extra personal hygiene products are stored in the supply room. The extra linen are stored in the hallway cabinet. The carbon dioxide detectors and smoke detectors are inspected and they are all working probably.

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: PASO REAL HOME	FACILITY NUMBER: 198603303
	VISIT DATE: 08/15/2023

NARRATIVE

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3. Operational Requirement: The facility is approved for four (4) non-ambulatory only. Currently the facility has three non-ambulatory and one ambulatory clients in the facility which is under the fire department requirement. The fire drill was conducted on 8/2/23 and the last earthquake drill was conducted on 7/3/23. The facility has a backyard with a shaded area (umbrella) with table and chairs for client to utilize the outdoor activity. Clients are allowed to attend or participate community activities if they want to or if they have the opportunity.

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

5.Personnel Record-Training: All the staff files are stored in the administrator office in another facility. All the staff are over 18 years old and they are background check cleared and associated with the facility. All the staff have the required documents in their personnel files which all the updated training hours, first aid certificate, health screening and TB Test result. The facility administrator is Tomasa Coronado and her certificate is expired on 5/19/2024 and she has the updated HIV and TB training certificate dated on 3/18/2022.

6. Client's 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's Record-Incident Reports: All the clients files are stored in the staff office. LPA reviewed all four (4) clients files and they all have the required documents in their files which are included face sheet, admission agreement, functional capabilities assessment, health screening, TB test result, ambulatory status and medication list.

8. Food Service: The facility has sufficient food supply in the facility which includes 2 days perishable and 7 days non-perishable. One of the client is currently on low carbohydrate diet per physician order but for the other clients, the staff would also chop the food for clients to prevent choking. All the food in the refrigerator and kitchen are stored probably. The refrigerator temperature is maintained in the required temperature limit.

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)

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: PASO REAL HOME	FACILITY NUMBER: 198603303
	VISIT DATE: 08/15/2023

NARRATIVE

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9. Health Related Services: The client's medication are stored and locked in the kitchen cabinet which are inaccessible to clients. LPA inspected all four (4) clients medication and medication record, they are all seemed accurate and up-to-dated. The first aid kit is stored in the supply room and inaccessible to clients. LPA inspected the facility first aid kit and it has all the required items in the kit.

10. Incidental Medical Services: Currently the facility does not have any client who has prohibited health condition or restricted health condition.

11. Disaster Preparedness: The facility has an updated Emergency Disaster Plan (LIC610D) and its dated on 8/30/22. The last emergency disaster drill was conducted on 7/3/23. The facility also has a two temporary alternative shelter location. All the staff have the required emergency disaster training.

12. Emergency Intervention: The facility does not use any restraint or CPI in this facility but all the staff have the updated CPI training certificate.

No deficiencies were observed during today's visit.

Exit Interview conducted and 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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