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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603361
Report Date: 06/11/2022
Date Signed: 06/11/2022 10:25:12 AM

Document Has Been Signed on 06/11/2022 10:25 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:HASU COMPASSIONATE CARE HOMEFACILITY NUMBER:
198603361
ADMINISTRATOR:JANET OBONGFACILITY TYPE:
735
ADDRESS:20312 SHADOW MOUNTAIN RD.TELEPHONE:
(909) 631-8521
CITY:WALNUTSTATE: CAZIP CODE:
91789
CAPACITY: 4CENSUS: 3DATE:
06/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:08 AM
MET WITH:Administrator, Janet ObongTIME COMPLETED:
10:35 AM
NARRATIVE
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Licensing Program Analyst (LPA) Vasallo conducted an annual required visit. LPA met Administrator, Janet Obong and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the physical plant, COVID-19 procedures, reviewed clients' medications and records and observed the food supply. The facility cares for adults with intellectual disabilities and is vendorized by San Gabriel/Pomona Regional Center as a Level 4 facility.

All client bedrooms were toured. One client bedroom has 2 beds (shared room) and there are 2 private rooms. The rooms have the required linen, dresser, light, and sufficient closet space. Both client bathrooms were toured and the hot water was 106.3 degrees which is within the required 105 - 120 degrees. There were no toxic chemicals accessible to clients. All chemicals are locked in the kitchen cabinets. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and are operating properly. The common areas include the living room and dining area. These areas are clean and have the required furniture. Facility currently has at least a 30-day supply of PPEs. There are no cameras inside or outside the facility. There is a screening station with PPEs at the entrance of the facility. Staff document client temperatures and symptoms daily as required.

Client files were reviewed to confirm emergency contacts are updated. Staff files were reviewed to confirm health screenings, training and fingerprint clearances. Staff #1 (S1) was working at the facility at the time of the visit and Administrator confirmed S1 does not have a fingerprint clearance. All clients' medications were reviewed. Medications are documented properly and given as prescribed.

Per California Code of Regulations, Title 22, the deficiencies observed during the visit are documented on the attached 809D. Exit interview held. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Tony Vasallo
LICENSING EVALUATOR SIGNATURE: DATE: 06/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/11/2022
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 06/11/2022 10:25 AM - It Cannot Be Edited


Created By: Tony Vasallo On 06/11/2022 at 10:08 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: HASU COMPASSIONATE CARE HOME
FACILITY NUMBER: 198603361

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(d)
Criminal Record Clearance
(d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations made, records reviewed and interviews conducted, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. Staff #1 (S1) was observed working at the facility and administrator confirmed S1 does not have a fingerprint clearance.
POC Due Date: 06/13/2022
Plan of Correction
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S1 will not be allowed to work until the fingerprint clearance has been processed. S1 will document the action that will be taken and will certify that all staff will be fingerprinted and associated to the facility prior to working.
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:Wei Siew Ho
LICENSING EVALUATOR NAME:Tony Vasallo
LICENSING EVALUATOR SIGNATURE:
DATE: 06/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2022


LIC809 (FAS) - (06/04)
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