198603361-7-11-2025-28-AS-BPEA-DJGQVE-20250711123012

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603361
Report Date: 07/11/2025
Date Signed: 07/11/2025 12:31:07 PM

Document Has Been Signed on 07/11/2025 12:31 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 HOME		FACILITY NUMBER:	198603361
ADMINISTRATOR/ DIRECTOR:	JANET OBONG		FACILITY TYPE:	735
ADDRESS:	20312 SHADOW MOUNTAIN RD.		TELEPHONE:	(909) 631-8521
CITY:	WALNUT	STATE: CA	ZIP CODE:	91789
CAPACITY: 4		CENSUS: 4	DATE:	07/11/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Janet Obong - Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced required-1 year inspection. LPA met with Janet Obong, Administrator and discussed the purpose of today's visit. The facility cares for developmentally disabled adults, age range 18 through 59. Facility is licensed for (4) non ambulatory, of which (1) may be bedridden, bedroom #1 or bedroom #3 approved for bedridden clients. The facility is vendorized by San Gabriel Pomona Regional Center. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained. Staff are adhering to infection control requirements. The facility has an Infection Control Plan and reviews the infection control procedures in the facility annually. Physical Plant & Environment Safety: This facility is a single story home consists of (3) client bedrooms, (1) staff room, office area, (2) bathrooms, kitchen, dining room, living room with fireplace, backyard, laundry area in the attached garage. Currently, there are (4) clients residing in the home. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, chair and sufficient closet space. The smoke alarm in the staff room is not operational. Laundry area is in the attached garage.Knives, cleaning solutions, and disinfectants are locked in a kitchen cabinet and inaccessible to clients. The cabinet under the kitchen sink is dirty, it has cobwebs and some small insects in it. There are no firearms or weapons stored at the facility. Water temperature readings measured in bathroom #1 is 114 deg F and bathroom #2 is 83.4 deg F which is not within the required 105 - 120 degrees Fahrenheit. Exit doors are free of any obstruction and there are no pools or large bodies of water. Backyard was inspected and has a shaded area and sitting area. Operational Requirements: Fire and earthquake drills are conducted on a regular basis, last drill was conducted on 06/17/2025. LPA observed a fire extinguisher in the kitchen has not been serviced since 2022, there are no other fire extinguishers in the facility. Administrator stated that a copy of the Surety bond insurance certificate will be emailed to LPA. The facility provides a shaded and furnished outdoor activity area. Sample menu and a weekly schedule of when meals and snacks are to be served is posted on the refrigerator door. ***Refer to LIC 809C for the continuation of this report.***

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: HASU COMPASSIONATE CARE HOME	FACILITY NUMBER: 198603361
	VISIT DATE: 07/11/2025

NARRATIVE

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Staffing: A total of (7) staff members including the Administrator provide care and supervision to the clients. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. Administrator certificate is valid and expires on 12/23/2026. Administrator has valid HIV/AIDS Training certificate (completed on 04/230/2025).
Personnel Records-Training: LPA reviewed (3) staff files including the Administrator. Proof of staff training, health clearance, and vaccinations are current.
Client Rights-Information: Client personal rights are posted. Facility provides internet and phone service to the clients. Facility did not have a doctor's order for (2) clients' (C1 & C2) 1/2 bed rails.
Client Records-Incident Reports: LPA reviewed all client files which are maintained in the facility. Identification and Emergency Information, Admission Agreement, Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Special Incident Reports, IPPs, Client Personal Property and Clients Personal Rights observed.
Food Service: There is sufficient food supplies of 2-day perishable and 7-day supplies of non-perishable items. The food is properly stored in the refrigerator. There are no clients with special diets residing at this facility. Pesticides and cleaning supplies are kept away from the food preparation areas.
Health Related Services: The medications are centrally stored and in their original containers. During the visit, the medication cabinet was unlocked and Administrator locked it immediately. Facility maintained a 30-day supply of medications. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician.
Incidental Medical Services: Per Administrator, there are no clients at this home with incidental medical services nor have a restricted health condition.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan.
Emergency Intervention: Not-Applicable.

Deficiencies cited and Technical Assistance and Technical Violation issued. Exit interview, appeals rights and a copy of this report was provided to Janet Obong, Administrator.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/11/2025 12:31 PM - It Cannot Be Edited

Created By: Bennette Pena On 07/11/2025 at 11:58 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: HASU COMPASSIONATE CARE HOME	FACILITY NUMBER: 198603361
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80020(a)

Fire Clearance

(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, the licensee did not comply with the section cited above in that LPA observed a fire extinguisher in the kitchen has not been serviced since 2022, there are no other fire extingushers in the facility. This poses an immediate health and safety risk to clients in care.
	POC Due Date: 07/14/2025
	Plan of Correction
1 2 3 4	Administrator agreed to purchase a new fire extinguisher and ensure that it is either serviced or replaced annually. Proof of purchase will be submitted to CCL/LPA by POC due date.

Type A

Section Cited

CCR

80075(k)(1)

Health-Related Services

(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. 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 in that LPA observed the medication cabinet was unlocked which poses an immediate health, safety or personal rights risk to clients in care.
	POC Due Date: 07/11/2025
	Plan of Correction
1 2 3 4	Administrator locked the medication cabinet immediately and in the presence of LPA. *DEFICIENCY CLEARED DURING THE VISIT.*

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	David Sicairos
NAME OF LICENSING PROGRAM MANAGER:

	Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/11/2025 12:31 PM - It Cannot Be Edited

Created By: Bennette Pena On 07/11/2025 at 11:58 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: HASU COMPASSIONATE CARE HOME	FACILITY NUMBER: 198603361
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients 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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that water temperature readings measured in bathroom #2 is 83.4 deg F which is not within the required 105 - 120 degrees Fahrenheit which poses/posed a potential health, safety or personal rights risk to clients in care.
	POC Due Date: 07/18/2025
	Plan of Correction
1 2 3 4	Administrator will ensure that the water in bathroom #2 shall deliver hot water and attain a hot water temp between 105-120 deg F as required. Administrator to send a week log of hot water temperature reading for bathroom #2 and submit to CCL/LPA by POC due date.

Type B

Section Cited

CCR

80072(a)(8)(B)

Personal Rights

(B) A written order from the client's physician indicating the need for the postural support shall be maintained in the client's record. The licensing agency shall be authorized to require additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on bservation, interview, record review, the licensee did not comply with the section cited above in that the facility did not have a doctor's order for (2) clients' (C1 & C2) 1/2 bed rails which poses/posed a potential health, safety or personal rights risk to clients in care.
	POC Due Date: 07/18/2025
	Plan of Correction
1 2 3 4	Administrator is to ensure that Title 22 Section 80072 regulations are met at all times. Administrator will obtain a doctor's order for C1 and C2's bed rails and submit a copy to CCLD/LPA by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	David Sicairos
NAME OF LICENSING PROGRAM MANAGER:

	Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025

LIC809 (FAS) - (06/04)

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