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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603361
Report Date: 06/16/2023
Date Signed: 06/16/2023 05:48:01 PM

Document Has Been Signed on 06/16/2023 05:48 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: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: 4DATE:
06/16/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
12:06 PM
MET WITH:Janet Obong, AdministratorTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to continue the annual inspection. LPA arrived and met with Administrator, Janet Obong.

LPA conducted the following domains during the visit today:
Staffing: There is sufficient staffing at the facility with at least 2 staff in each shift. The overnight shift staff are awake. Staff are fingerprint cleared and associated to the facility. Personnel Records-Training: Staff files are maintained at the facility. Administrator (Janet Obong) certificate expires on 12/23/24. The administrator training on HIV/AIDS and TB had expired on 4/12/23 and the CPR/First Aid certificate had also expired on 3/6/23. LPA reviewed (2) additional personnel files and they have the required documents.
Client Rights - Information: Clients are afforded privacy and provided devices with internet access.
Client Records-Incident Reports: Client files are maintained at the facility. LPA reviewed all (4) client files. Client #3 was missing current TB test. Client #3 was admitted to the facility on 5/28/22 and the TB test result on file was dated 7/26/19. The other client files have the required documents. Health-Related Services: The medications are centrally stored and locked. The facility uses the Medication Administration Record (MAR) log to document medications given. LPA reviewed medications for all 4 clients and they are being administered as prescribed by the physician. Incidental Medical & Dental: There are no clients who require health services or have a health condition that need to be monitored more carefully. Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Staff are provided training on the emergency procedures and know where the utility shutoff valves are located. The client roster is posted and the clients' face sheet have been updated.

The deficiencies are issued on the LIC809D page. An exit interview was held. A copy of this report, appeal rights, and LIC809D were given to the administrator.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2023
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 06/16/2023 05:48 PM - It Cannot Be Edited


Created By: Cynthia D Chan On 06/16/2023 at 04:18 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: HASU COMPASSIONATE CARE HOME
FACILITY NUMBER: 198603361

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(k)
85064 Adminstrator Qualifications and Duties
(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that the administrator's HIV and TB training have expired on 4/12/23 which poses a potential health and safety risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
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The administrator shall register for the training and provide the date of training or certificate of completion to LPA by POC 6/30/23.
Type B
Section Cited
CCR
80075(f)
80075 (f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in which the administrator's CPR and First Aid certificates have expired on 3/6/23 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
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The administrator shall obtain CPR and First Aid training and submit the certificate to LPA by POC due date 6/30/23.
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:Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/16/2023 05:48 PM - It Cannot Be Edited


Created By: Cynthia D Chan On 06/16/2023 at 04:30 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: HASU COMPASSIONATE CARE HOME
FACILITY NUMBER: 198603361

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(b)(1)
80069 Client Medical Assessment
(b) In ARFs , prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.
(1) Such assessment shall be performed by a licensed physician, or designee, who is also a licensed professional, and the assessment shall not be more than one year old when obtained.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in which 1 out of 4 clients did not have current TB test results on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
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The administrator shall schedule a medical appointment to obtain TB test results for Client #3 and submit the results by POC due date 6/30/23.
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:Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2023


LIC809 (FAS) - (06/04)
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