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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603314
Report Date: 07/20/2023
Date Signed: 07/20/2023 03:49:47 PM

Document Has Been Signed on 07/20/2023 03:49 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:ADULT BASIC LEARNING ENVIRONMENT, INCFACILITY NUMBER:
198603314
ADMINISTRATOR:CUEVAS, MIRIAMFACILITY TYPE:
775
ADDRESS:843 W GLENTANA ST.TELEPHONE:
(909) 335-3022
CITY:COVINASTATE: CAZIP CODE:
91723
CAPACITY: 45CENSUS: 10DATE:
07/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:18 AM
MET WITH:Miriam CuevasTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 07/15/2023 at 9:25am. LPA was met by Staff #5 (S5) and explained the purpose of the visit. Administrator Miriam Cuevas arrived shortly after and assisted in facility tour. The facility is licensed serve clients 18 years and older. All clients receive services from San Gabriel Valley/Pomona Regional Center. The facility is approved 45 non-ambulatory. LPA Ramirez requested and obtained copies of Personnel Report (LIC 500), and Resident Roster (LIC 9020).

LPA OBSERVATIONS: Tour began at 9:15am and was led by S5. The facility is a single-story commercial building located in a commercial/industrial area with four (4) client activities rooms, kitchen, two (2) staff offices, three (3) unisex bathrooms, four (4) storage closets, one (1) changing room, and lobby area/guest area.

Kitchen: LPA Ramirez observed a refrigerator and kitchen sink. Refrigerator was observed to be in working order. Facility has a refrigerator to store clients packed lunches from home. LPA Ramirez observed some extra juices in a lower refrigerator drawer. Per S5, the facility has the drinks on hand in case a client forgets their drink or snack. Kitchen sink water temperature was measured at 120.7 degrees F. LPA Ramirez observed a fully charged fire extinguisher in this area. LPA Ramirez observed facility sketch plans in this area.

Client Activities Room 1 - 4: Activity rooms 1 – 4 were all observed with various board games, books, chairs, tables, crayons, coloring books, couches, karaoke machine, television, drum set, and various cabinets and cubbies for clients to store their personal belongings. LPA Ramirez observed hand sanitizer throughout various locations in activities room 1 – 4. LPA Ramirez observed facility sketch plans in each room.

Storage Closets 1 -4: LPA Ramirez observed storage closets to be locked and inaccessible to clients in care. Storage closets contained mop buckets, cleaning and disinfectant supplies, gloves, hand sanitizer, face masks and paper supplies.

SEE 809-C for continuation.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2023
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 07/20/2023 03:49 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 07/20/2023 at 10:58 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: ADULT BASIC LEARNING ENVIRONMENT, INC
FACILITY NUMBER: 198603314

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures 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, client bathrooms #1, 2, and 3 were not within in 105 - 120 degree F as required, the licensee did not comply with the section cited above in 10 out of 10 clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/21/2023
Plan of Correction
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Licensee will provide plan to address hot water temperature controls in client bathrooms 1-3. Licensee will continue to docuement water temperature for the next 7 business days and email logs to LPA Ramirez by 7/31/23.
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: 07/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2023


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: ADULT BASIC LEARNING ENVIRONMENT, INC
FACILITY NUMBER: 198603314
VISIT DATE: 07/20/2023
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Changing room: LPA Ramirez observed a large adult size padded table and a three (3) drawer rolling cart nearby. LPA Ramirez observed the cart to contain gloves, hand sanitizer, and blue changing pads. LPA Ramirez observed facility sketch plans in this area.

Client Bathrooms 1 - 3: Signs promoting hand washing were observed. Water temperature in client bathroom#1 was measured at 136.1 degrees F which is not within the required 105 – 120 degrees F. Client bathroom #2 was observed to be clean and water temperature was measured at 124.2 degrees F which is not within the required 105 – 120 degrees F. Client bathroom #3 was observed to be clean and water temperature was measured at 128.2 degrees F which is not within the required 105 – 120 degrees F. LPA Ramirez observed the water temperature quickly drop in client bathroom #2 to 89.9 degree F within a few seconds of testing water. Administrator Cuevas provided LPA Ramirez with a water temperature log dated 7/5/23 ,for client bathroom 1-3, which shows water temperature taken on 7/5/23 were within required limits.

Emergency Drills(Conducted every 6 months): Proof of last documented earthquake drill was conducted 5/01/23 at 10:23 am and ended at 10:26 am. Five (5) staff and seven (7) clients participated in drill.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide and smoke detectors in hallways. LPA Ramirez observed posted Emergency Disaster Plan. LPA Ramirez observed several fully charged fire extinguishers throughout the facility.

Staff Personnel Files: Staff files are maintained at facility. Seven (7) staff files were reviewed. LPA Ramirez reviewed current First Aid/CPR certification, Health Screening and Tuberculosis Screening on file, and Criminal record clearance.

Infection Control Plan: LPA Ramirez reviewed and obtained a copy Infection Control Plan. Infection Control Plan was last updated 6/3/23.

LPA Ramirez was unable to interview clients in care due to clients being non-verbal and cognitive impairments.

Deficiency is being cited during visit. Exit interview was conducted with Administrator Cuevas and a copy of this report, 809-D, and appeals rights were provided.

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

DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023
LIC809 (FAS) - (06/04)
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