198603311-5-26-2023-28-AS-THEA-CS7PJZ-20230526112223

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603311
Report Date: 05/26/2023
Date Signed: 05/26/2023 11:23:50 AM

Document Has Been Signed on 05/26/2023 11:23 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:	NURTURE AT ADWEN		FACILITY NUMBER:	198603311
ADMINISTRATOR:	TORRES, PRINCESS W.		FACILITY TYPE:	735
ADDRESS:	7612 ADWEN STREET		TELEPHONE:	(424) 362-6566
CITY:	DOWNEY	STATE: CA	ZIP CODE:	90241
CAPACITY: 6		CENSUS: 4	DATE:	05/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:08 AM
MET WITH:	Derry Sandajan - House Manager		TIME COMPLETED:	11:30 AM

NARRATIVE

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Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Derry Sandajan (House Manager) who assisted with the visit. The facility is licensed to serve 6 non-ambulatory clients ages 18 to 59 years old.

The facility is a single-story home located in a residential. A tour of the facility includes: dining room, kitchen, living room, 3 client bedrooms, 2 bathrooms, attached garage, front yard, backyard, and a locked toolshed.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents’ medications. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan posted by the entrance.

Physical Plant & Environment Safety: There are 3 client bedrooms, 2 bathrooms, living room, dining room, kitchen, attached garage, front yard, backyard and a locked toolshed/storage room. All bathrooms are clean and operational. Clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. There were a few paint cans near garage and in front yard that were closed securely but accessible to clients a TV was issued during today’s visit, assistant administrator had staff properly dispose of paint cans prior to end of visit. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available. The hot water temperature was tested in both client bathrooms and measured at 107.7 – 117.6 degrees F which are within the required range of 105-120 degrees. All storage areas for cleaning solutions, toxins, knives, and hazardous items are in a secured cabinet and inaccessible to clients.

(Continued on LIC 809-C)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023

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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Document Has Been Signed on 05/26/2023 11:23 AM - It Cannot Be Edited

Created By: Tena Herrera On 05/26/2023 at 10:44 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: NURTURE AT ADWEN	FACILITY NUMBER: 198603311
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(g)

Building and Grounds

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as LPA observed there to be cleaning solutions located in unlocked cabinet in client bathroom, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/26/2023
	Plan of Correction
1 2 3 4	Plan of Correction was cleared during todays visit. House manager removed cleaning supplies and placed in locked garage with all other cleaning supplies.

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:

Tena Herrera

LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023

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: NURTURE AT ADWEN	FACILITY NUMBER: 198603311
	VISIT DATE: 05/26/2023

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LPA observed disinfectant and cleaning supply stored in an unlocked cabinet in the client bathroom, assistant administrator immediately removed the supplies and stored in locked garage with other cleaning supplies (this was cited during todays visit). The last Fire/Emergency Drill was conducted on 03/15/23. Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguisher was observed in the kitchen area and is fully charged.
Operational Requirements: There are currently 4 ambulatory residents residing at the facility.
Staffing: There appears to be sufficient staffing at all times in the facility. Administrator Princess Torres certificate expires on 6/8/2024.
Personnel Records-Training: Staff has criminal record clearance and current first aid and CPR. Staff files are maintained at the facility stored electronically with a secured password setting. Staff have current CPR/first aid training and sufficient on-going training.
Client Rights-Information: Residents personal rights poster is posted in the dining room.
Client Records-Incident Reports: Client files are kept locked in a cabinet in office area and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report (on tablet with other electronic files), Pre-admission appraisal/Appraisal Needs & Services Plan.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Service: Staff designated to administer medication has the proper annual training on file. Medication is properly labeled and are centrally stored in a locked cabinet and are in their original containers. During the visit today, LPA reviewed all 4 clients’ medication no issues were observed.
Incidental Medical & Dental: All medications for clients are kept locked and inaccessible to other clients.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites.
Emergency Intervention: Residents at this facility do not have restraints nor do they require the use de-escalation techniques.
Per California Code of Regulations, Title 22, and California Health and Safety Code, there was one deficiency and one technical violation issued during todays visit.

Exit interview held and a copy of the report and appeal rights were provided to House Manager Derry Sandajan.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023

LIC809 (FAS) - (06/04)

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