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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603325
Report Date: 04/24/2023
Date Signed: 04/24/2023 12:16:33 PM

Document Has Been Signed on 04/24/2023 12:16 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:EMJ HOME CAREFACILITY NUMBER:
198603325
ADMINISTRATOR:TORRES, MICHAELFACILITY TYPE:
735
ADDRESS:1486 LASSITER DRIVETELEPHONE:
(909) 957-5620
CITY:WALNUTSTATE: CAZIP CODE:
91789
CAPACITY: 5CENSUS: 5DATE:
04/24/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Alicia Federspiel, house managerTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to continue the annual inspection. LPA met with the house manager, Alicia Federspiel, and explained the reason for the visit.

LPA completed the remainder of the inspection using the CARE tool. The following were observed:
Staffing: There are sufficient staffing to assist the current 5 clients with their needs. There is one awake overnight staff to supervise clients. Personnel Records - Training: The staff are all fingerprint cleared and associated to the facility. LPA reviewed records for 4 staff and they have the required documents in their files - health screening form, TB test result, Personnel record, employee rights, First Aid/CPR certificate, and training log. Staff have current first aid and CPR training. Client Rights - Information: There are no clients who require postural supports at this home. They are provided with their own tablets and have internet access. Client Records - Incident Reports: LPA reviewed all 5 client files today. Each of the files has the required documents such as the admission agreement, medical assessment including TB results, current IPP reports from the regional center, and behavioral plans. Health-Related Services: Medications are centrally locked and inaccessible to clients. LPA reviewed medications for all 5 clients. There were no discrepancies found and PRN meds are documented when given. Incidental Medical Services: There is one client who is diabetic and can self-inject the insulin. There are no other health restricted conditions such use of catheters, any stage 3 or 4 wounds, naso-gastric/naso-duodenal tubes, or other conditions that require 24-hour nursing care or monitoring. Disaster Preparedness: The facility has an emergency and disaster plan. The plan has at least 2 shelter locations and instructions to shutoff utility valves. The facility is currently conducting monthly fire drills. LPA informed house manager about the different emergency scenarios drills that shall be conducted at least least quarterly for each shift. Emergency Intervention: Facility staff have CPI training but do not use any manual restraints on clients. Per the house manager, they would only use the redirection approach with clients.

No deficiencies observed today. An exit interview was held and a copy of this report was given to staff Maria.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2023
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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