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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603306
Report Date: 05/11/2024
Date Signed: 05/11/2024 02:36:30 PM

Document Has Been Signed on 05/11/2024 02:36 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:KENDALL GUEST HOME 1FACILITY NUMBER:
198603306
ADMINISTRATOR/
DIRECTOR:		GALLEGOS, ANAFACILITY TYPE:
735
ADDRESS:4702 N MAXSON RDTELEPHONE:
(909) 631-8521
CITY:EL MONTESTATE: CAZIP CODE:
91732
CAPACITY: 6CENSUS: 6DATE:
05/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:14 AM
MET WITH:Caregiver Yolanda ValdezTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analysts (LPAs) Kimberly Ramirez conducted an unannounced Annual Inspection visit on 05/11/2024. LPA Ramirez were met by Caregiver Yolanda Valdez and explained the purpose of the visit. This facility is licensed as an Adult Residential Facility and is serviced by San Gabriel/Pomona Regional Center. The facility is licensed to serve SIX (6) developmentally disabled clients ages 18 and above; of which all must be ambulatory. During today’s visit, LPA Ramirez observed one (1) caregiver providing direct care and supervision to clients in care. LPA Ramirez requested and obtained copies of Personnel Report, and Client Roster

LPA OBSERVATIONS: The facility is a single-story home that contains three (3) bedrooms, two (2) client bathrooms, living room, kitchen, dining room, laundry room, backyard, shaded patio area, and enclosed activity area.

Front Yard: LPA Ramirez observed front yard to be free of hazards. LPA Ramirez observed front patio screens to be torn and contain holes. LPA Ramirez will issued Type B deficiency.

Kitchen: LPA Ramirez observed appliances to be clean and in working order. LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located kitchen cabinet, to be inaccessible to one (3) out of six (6) clients in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants to be inaccessible to three (3) out of six (6) clients in care. Signs promoting hand washing were observed in this area. No hot water was observed to be running from kitchen faucet. LPA Ramirez will issue Type B deficiency.

Dining Room/Living room: Dining room was observed to contain one table with several chairs. The living room was observed to contain plenty of lighting. LPA Ramirez observed a fully charged fire extinguisher nearby. LPA Ramirez observed nearby thermostat to read 70 degrees F.

SEE 809-C for continuation.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: KENDALL GUEST HOME 1
FACILITY NUMBER: 198603306
VISIT DATE: 05/11/2024
NARRATIVE
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Linen Closet/Supply Closet: Observed to contain plenty linens, towels, and hygiene products.

Client Rooms 1 - 3: All clients bedrooms are shared. LPA Ramirez observed all client bedrooms to contain the required linens, furnishings, and lighting. Dressers in client bedroom#1, which belongs to C1, was observed to be broken and not working to its original design. LPA Ramirez will issued Type B deficiency.

Bathroom 1-2: Water temperature in bathroom#1 was measured at 106.9 degrees F, which is within Title 22 regulation. Bathroom#2 water temperature was measured at 112.6 F degrees. Both bathrooms were observed to be clean and contain grab bars near toilets.

Backyard: No large bodies of water were observed. LPA Ramirez observed enclosed activity room with one (1) exercise bike and arts and crafts.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide and smoke detectors in hallways. Smoke detectors were observed to be operable during visit. Fully charged fire extinguishers were observed throughout the facility.

Personnel Records: Personnel records are maintained at the facility. LPA Ramirez requested to inspect personnel records. Facility staff were unable to gain entry to staff office and Administrator Ana Gallegos was unavailable to to another staff allow LPA access to these records. LPA Ramirez issued Type B deficiency.

Client Records: Client files are maintained at the facility. LPA Ramirez reviewed six (6) client records. No deficiency was observed. Admissions Agreement, Medical Assessment, Consent Forms, Appraisal and Needs and Services plan, I.D and Emergency Information, TB Test, Centrally Stored Medication Record, and Personal Rights Form.

Four (4) deficiencies were cited today. Exit interview was conducted. A copy of this report, 809-D, and appeals rights was provided.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 05/11/2024 02:36 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 05/11/2024 at 12:59 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: KENDALL GUEST HOME 1
FACILITY NUMBER: 198603306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, screens in front patio area were observed with holes and tears,the licensee did not comply with the section cited above in 6 out of 6 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/25/2024
Plan of Correction
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Licensee will repair screens and send picture of repairs by 05/25/2024. Proof must be submitted by 05/25/2024 via fax.
Type B
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
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Based on observation, no hot water was observed to be running from kitche sink, the licensee did not comply with the section cited above in 6 out of 6 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/25/2024
Plan of Correction
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Licensee will provide invoice of repair by 05/25/2024 via fax.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/11/2024 02:36 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 05/11/2024 at 01:09 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: KENDALL GUEST HOME 1
FACILITY NUMBER: 198603306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(c)
80066 Personnel Records (c) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, facility office was locked and personnel records located inside were inaccessible to LPA during inspection, the licensee did not comply with the section cited above in 6 out of 6 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/25/2024
Plan of Correction
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Licensee will develop a plan that will address how personnel records will be accessible to this licensing agency upon demand.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/11/2024 02:36 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 05/11/2024 at 01:37 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: KENDALL GUEST HOME 1
FACILITY NUMBER: 198603306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, dresser in client bedroom#1 which bemongs to C1, was observed to be broken and not working properly,the licensee did not comply with the section cited above in 1 out of 6 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/25/2024
Plan of Correction
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Licensee will repair or replace C1 dresser and send invoice and picture via fax to LPA Ramirez.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2024


LIC809 (FAS) - (06/04)
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