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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603424
Report Date: 06/20/2023
Date Signed: 06/20/2023 12:43:39 PM

Document Has Been Signed on 06/20/2023 12:43 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:NEW HOPE HOME CAREFACILITY NUMBER:
198603424
ADMINISTRATOR:MANZANO, CARMENCITAFACILITY TYPE:
735
ADDRESS:2146 VIRGINIA AVE.TELEPHONE:
(909) 306-7757
CITY:POMONASTATE: CAZIP CODE:
91766
CAPACITY: 4CENSUS: 2DATE:
06/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Leonora NgTIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elizabeth Irra conducted the required annual inspection. LPA met with Leonora Ng/S-1 and discussed the purpose of today’s visit.

This is a single story home that consists of: (5) bedrooms, (3) bathrooms, living room, kitchen, dining room, family room, laundry unit and an attached garage. Clients from this home receive case management services provided by San Gabriel Pomona Regional Center. C-1 and C-2 are above the age of 59.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place.

Operational Requirements: The fire clearance is approved for (4) ambulatory clients. Last Disaster Drill was conducted on 01/15/23. Staff are adhering to operational requirements.

Physical Plant & Environment Safety: Smoke alarms were tested and operable. Fire extinguisher is located in the dining area and appeared to be full. Carbon monoxide detector is located in hallway (tested and operable). Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. There are no firearms or weapons stored at the facility. Hot water supply measured at: 114.2* near bedroom #1 and 113.0* near bedroom #3 and #4.

Refer to LIC 809C for the continuation of this report.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2023
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 4
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: NEW HOPE HOME CARE
FACILITY NUMBER: 198603424
VISIT DATE: 06/20/2023
NARRATIVE
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Staffing: There is sufficient staffing at the facility. Administrator Certificate for Carmencita Manzano expires 05/21/24. HIV Certificate for Carmencita Manzano is dated 03/16/20 and TB Certificate is dated 04/07/21. Deficiency cited on LIC 809D. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Staff #1 (S-1) and Staff #2 (S-2). Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Staff have on-going training.

Client Rights-Information: Client rights are posted and included in Client files. Per S-1, there are no clients using postural supports.

Client Records-Incident Reports: LPA reviewed Client files for Client #1 (C-1) through Client #2 (C-2). Client files are maintained at the facility. Admission Agreement, Physician's Report (including T.B), Weight Record, Consent For Medical Treatment, Individual Program Plan (IPP) and Client Rights were observed.

Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. Per S-1, there are no clients on special diets. 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 bubbled packed. LPA reviewed medication for C-1 through C-2. 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 S-1, C-2 has a restrictive health condition and a plan is on file.

Disaster Preparedness: The facility does not have the Emergency Disaster Plan (LIC610D/9 pages) in place. Deficiency cited on LIC 809D.

Deficiencies cited. Exit interview, appeals rights and a copy of this report was provided to Leonora Ng/S-1. Note: LPA was experiencing technical difficulties during this visit.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/20/2023 12:43 PM - It Cannot Be Edited


Created By: Elizabeth Irra On 06/20/2023 at 11:14 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: NEW HOPE HOME CARE
FACILITY NUMBER: 198603424

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.4(c)
(c) When a licensee admits or retains any person 60 years of age or older, the licensee shall ensure that all of the following information is contained in the person's file: (1)Completed Functional Capabilities Assessment, required by Section 80069.2.
(2) Completed Needs and Services Plan, required by Section 85068.2. If one or more age-related care needs are identified by the provider or the referring source, the licensee shall ensure that the Needs and Services Plan specifies how such need(s) will be addressed. (3) Documentation of a medical assessment, signed by a physician, made within the last year.
(4) A letter of support from the person's conservator with placement authority, if applicable. (5)Letters of support, if any, from the person's placement officer, social worker, and/or mental health professional, if applicable, documenting that the Adult Residential Facility is the most appropriate setting for the person.

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 (2) out of (2) files reviewed which poses/posed a potential health, safety or personal rights risk to persons in care. Per file reviews, C-1 is the most recent client admitted that is above the age of (59).
POC Due Date: 07/03/2023
Plan of Correction
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Licensee to submit an age exemption for C-1 (with elements noted above) to LPA Irra 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.
SUPERVISOR'S NAME:Tony Vasallo
LICENSING EVALUATOR NAME:Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 06/20/2023 12:43 PM - It Cannot Be Edited


Created By: Elizabeth Irra On 06/20/2023 at 11:20 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: NEW HOPE HOME CARE
FACILITY NUMBER: 198603424

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(k)
Administrator 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 which poses/posed a potential health, safety or personal rights risk to persons in care. HIV Certificate for Carmencita Manzano is dated 03/16/20 and TB Certificate is dated 04/07/21.
POC Due Date: 07/03/2023
Plan of Correction
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Licensee to enroll to HIV and TB training for Carmencita Manzano and submit proof of enrollement to LPA Irra by POC due date.
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record view, the licensee did not comply with the section cited above as the facility did not have a complete disaster and mass casualty plan which poses/posed a potential health, safety or personal rights risk to persons in care. This standard is not met at evidence by: Facility does not have a complete Disaster and Mass Casualty Plan. LPA provided Administrator with guidance on how to retrieve the LIC 610D through the CDSS website.
POC Due Date: 07/03/2023
Plan of Correction
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Licensee to complete and submit the LIC 610D (9 pages) to 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.
SUPERVISOR'S NAME:Tony Vasallo
LICENSING EVALUATOR NAME:Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023


LIC809 (FAS) - (06/04)
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