198603408-6-3-2023-28-AS-BPEA-CSG8TM-20230603224806

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603408
Report Date: 06/03/2023
Date Signed: 06/03/2023 10:49:01 PM

Document Has Been Signed on 06/03/2023 10:49 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:	EASTERSEALS SOUTHERN CA - WEST MAPLE RESIDENCE		FACILITY NUMBER:	198603408
ADMINISTRATOR:	VAZQUEZ, LUDMILA		FACILITY TYPE:	735
ADDRESS:	9621 MAPLE ST		TELEPHONE:	(714) 834-1111
CITY:	BELLFLOWER	STATE: CA	ZIP CODE:	90706
CAPACITY: 4		CENSUS: 2	DATE:	06/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Administrator, Priscillah Houston		TIME COMPLETED:	06:15 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 visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Josefina Mendoza, Direct Service Professional II (DSP II) and Amalia Ordoveza, Direct Service Professional II (DSP II) and explained the purpose of the visit. Administrator, Priscillah Houston arrived at 3:00pm and assisted LPA with the inspection. 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 observed. There is a visitor sign-in station located near the front door. The staff are wearing masks throughout their shift and disposable gloves are used to clean and disinfect the high touched surfaces in the common areas. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Facility has COVID-19 signage posted in the facility. Bathrooms have the basic items required like, hand soap, toilet paper, and paper towels. Staff are adhering to infection control requirements. Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. A fire clearance for four (4) bedridden clients is in place. Certificate of Liability Insurance with James + Gable Insurance Brokers is valid and will expire on 07/01/2023. Administrator stated that the facility has a valid Surety Bond coverage in the amount of $2500 and will send a copy to CCL/LPA on or before 6/09/2023. Administrator will request a copy from the corporate office. Last Fire Drill was conducted on 5/01/2023. Physical Plant/Environment Safety: The facility is a single storey home located in a residential neighborhood, contains four (4) client bedrooms, two (2) full bathrooms, a family room, a living room, kitchen, dining area, office area, backyard, and attached garage. The facility is licensed to care for Developmentally Disabled Adults, ages 18 through 59, 4 non ambulatory of which (4) may be bedridden. Currently, there are (2) clients living in the facility who are over the age of 59. Age exception letter was approved. All clients residing at this facility receive case management services provided by Harbor Regional Center. Facility level is negotiated. The interior and exterior physical plant was inspected. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, nightstand, light, chair and sufficient closet space. Bathrooms have non-skid materials and contained hygiene supplies including liquid soap, paper towels, and toilet paper. The ceiling in bathroom #2 has water leak damage. The ceiling paint has bubbles and the dry wall was swelling. The Administrator stated that the maintenance person was contacted and scheduled to fix the ceiling next week. Exit doors are free of any obstruction and there are no pools or large bodies of water. The backyard was inspected and has a shaded area with tables and chairs for clients use. There are cameras located outside the home only. Attached garage was inspected and LPA observed sufficient supply of PPEs stored in the garage. Kitchen knives, sharps objects, cleaning supplies and toxic substances are locked and inaccessible to clients. There are two (2) fire extinguishers observed to be fully charged and both were last serviced on April 20,2023. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Hot water supply measured 113.2 deg. F in bathroom #1, and 116.2 deg. F in bathroom #2. ***CONTINUED ON LIC809-C***

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2023

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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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: EASTERSEALS SOUTHERN CA - WEST MAPLE RESIDENCE	FACILITY NUMBER: 198603408
	VISIT DATE: 06/03/2023

NARRATIVE

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Staffing: A total of four (4) 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.

Personnel Records/Staff Training: Reviewed files for two (2) staff. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Administrator certificate expired on 12/28/2022 and does not have a valid/current certificate. Administrator submitted renewal on 12/27/2022 but has not received the new certificate. During the visit, Administrator provided LPA the renewal payment receipt showing the amount paid.

Client Rights-Information: Client personal rights are posted. Per Administrator, facility provides internet services to all clients and have access to the facility phone. LPA attempted to interview the clients but unsuccessful due to C1 was non verbal and C2 was sleeping.

Client Records-Incident Reports: LPA reviewed Client files for C1-C2. Client files are maintained at the facility. Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Individual Program Plan (IPP), Behavioral Reports, Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights observed.

Food Service: There are sufficient food supplies of 2-day perishable and 7-day non-perishable items. The food is properly stored in the refrigerator (clean and well maintained). One client residing at this facility is under gastric tube feeding. Restricted Health Condition Care Plan is in place. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services The medications are centrally stored and in their original containers. Medications were reviewed for C1-C2 to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician.

Incidental Medical Services: One (1) client at this home has incidental medical services and under gastric tube feeding. A restricted health condition care plan is in place.

Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan.

Emergency Intervention: Not-Applicable.

Pursuant to Title 22, deficiency was cited on the attached 809D and Technical Assistance were issued. An exit interview was conducted, and a copy of this report and appeals rights were provided to the Administrator, Priscillah Houston.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/03/2023 10:49 PM - It Cannot Be Edited

Created By: Bennette Pena On 06/03/2023 at 05:41 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: EASTERSEALS SOUTHERN CA - WEST MAPLE RESIDENCE	FACILITY NUMBER: 198603408
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80066(e)

80066 Personnel Records (e) All personnel records shall be maintained at the facility site and shall be available to the licensing agency for review. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, the Administrator did not comply with the section cited above in which some of the personnel records and files cannot be reviewed in the facility.The files are in a locked cabinet and the Administrator did not have the key and cannot access it which poses/posed a potential health, safety or personal rights risk to clients in care.
	POC Due Date: 06/09/2023
	Plan of Correction
1 2 3 4	Licensee will ensure that personnel records and facility files are accessible to licensing agency upon inspection. Licensee will send a plan to CCL/LPA indicating how staff will be able to access records and files upon licensing requests to view the records by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

David Sicairos

LICENSING EVALUATOR NAME:

Bennette Pena

LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2023

LIC809 (FAS) - (06/04)

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