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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603368
Report Date: 09/10/2021
Date Signed: 09/10/2021 12:52:23 PM

Document Has Been Signed on 09/10/2021 12:52 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:FOXDALE HOME ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
198603368
ADMINISTRATOR:TOMINES, OLIVIAFACILITY TYPE:
735
ADDRESS:540 N. FOXDALE AVETELEPHONE:
(909) 306-4692
CITY:WEST COVINASTATE: CAZIP CODE:
91790
CAPACITY: 4CENSUS: 3DATE:
09/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Myrna Macalino & Mary Joe Ongbico; DSPsTIME COMPLETED:
01:07 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Sicairos conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPA met with DSP Myrna Macalino and explained the reason for the visit. Physical Plant was toured, sample record of medications were reviewed, and food supply was inspected.

The following was observed/inspected:
  • LPA and Ms. Macalino toured the home and inspected (3) client bedrooms, (2) bathrooms, kitchen, dining room, living room, office room, and detached garage. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the clients located in the backyard. Passageways and exits are free of obstruction. The water temperature was tested in bathroom #1 and bathroom #2 and measured at 120F which is within the required 105 - 120 degrees. Client bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have sufficient closet space. Clients beds have the required linen and the linen is in good condition. LPA observed bedroom door of Client #1 (C1) is damaged with holes and chipped paint. Smoke detectors were observed throughout the facility and were tested and operable during the visit. There is a carbon monoxide detector in the hallway of the home. There are (2) fire extinguishers located in the kitchen and in the garage and both are fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked in a kitchen drawer and are inaccessible to clients. Cleaning supplies and toxins are locked under the sink and are inaccessible to clients. First Aid kit was fully stocked with current manual.
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • Sufficient supply of 2 days perishable & 7 days non-perishable foods were observed.
  • (2) out of the (2) client medications were reviewed. Medications are centrally stored in a cabinet located in the hallway. LPA observed Furosemide 40mg for Client #1 was signed off on MARs for 09/08/21 however pill was still in the bubble pack.
  • Staff and Client files were not reviewed during today's visit.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on 809D. Exit interview held and a copy of the report along with appeal rights were provided.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: David Sicairos
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 09/10/2021 12:52 PM - It Cannot Be Edited


Created By: David Sicairos On 09/10/2021 at 11:53 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: FOXDALE HOME ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198603368

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(a)
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:

LPA observed on MARs for Client #1 dated 09/08/21 that Furosemide 40mg (AM) was signed off as given to client, however the pill was still in the bubble pack.
Deficient Practice Statement
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Based on medication review of Client #1, the Administrator did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/13/2021
Plan of Correction
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Administrator to submit an Incident Report regarding the missed medication dose for Client #1. Administrator to retrain staff members who pass out medications on proper medication procedures and submit a list of all staff members who attended the training and indicate what the training covered.
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:Rebecca Orendain
LICENSING EVALUATOR NAME:David Sicairos
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/10/2021 12:52 PM - It Cannot Be Edited


Created By: David Sicairos On 09/10/2021 at 12:12 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: FOXDALE HOME ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198603368

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:

During physical plant tour of the facility, LPA observed bedroom door of client #1 is damaged with holes and missing paint.
Deficient Practice Statement
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Based on Physical Plant tour, the Administrator did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2021
Plan of Correction
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Administrator to ensure facility is clean, safe, sanitary, and in good repair at all times. Administrator to ensure bedroom door of Client #1 is repaired and submit pictures of repairs by POC due date.
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:Rebecca Orendain
LICENSING EVALUATOR NAME:David Sicairos
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2021


LIC809 (FAS) - (06/04)
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