198603443-3-17-2023-28-AS-EIRA-CPZR4T-20230317124204

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603443
Report Date: 03/17/2023
Date Signed: 03/17/2023 02:42:53 PM

Document Has Been Signed on 03/17/2023 02:42 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:	DHASA CARE		FACILITY NUMBER:	198603443
ADMINISTRATOR:	DEBELA-SLEDGE, HURUBE		FACILITY TYPE:	735
ADDRESS:	2181 LARCHMONT ST		TELEPHONE:	(773) 718-0819
CITY:	POMONA	STATE: CA	ZIP CODE:	91767
CAPACITY: 4		CENSUS: 4	DATE:	03/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:25 AM
MET WITH:	Brandon Hampton/Hurube Debela-Sledge		TIME COMPLETED:	01:00 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) Elizabeth Irra conducted the required annual inspection. LPA was allowed entry by Brandon Hampton/S-1. LPA explained the purpose of today's visit. Hurube Debela-Sledge /Facility Administrator arrived at approximately 9:30 A.M.. The facility is licensed for (4) ambulatory clients ages 18 through 59. The fire clearance is approved for (4) ambulatory clients. All clients residing at this home receive case management services provided 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: The facility staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has sufficient PPE supplies, has an Infection Control Plan and Mitigation Plan. Facility has COVID-19 signage posted throughout the facility. Bathrooms have hand washing signs, soap and paper towels. Staff are adhering to infection control requirements. Operational Requirements: The fire clearance is approved for (4) ambulatory clients. Last Fire Drill and Earthquake Drill were conducted on 12/12/2022. Staff are adhering to operational requirements. Refer to LIC 809C for the continuation of this report.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023

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: DHASA CARE	FACILITY NUMBER: 198603443
	VISIT DATE: 03/17/2023

NARRATIVE

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Physical Plant & Environment Safety: This facility consists of (4) private bedrooms, (2) bathrooms (one bathroom is located inside a client bedroom/master bedroom), living room, kitchen, dining room, activity room and an attached garage. The laundry unit is set-up inside the garage. Smoke alarms were tested and operable. Fire extinguisher appeared to be full and was last serviced on 01/18/23. Carbon monoxide 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 108.2* in the kitchen, 107.4* in the hallway bathroom and 110* in the bathroom inside the master bedroom.

Staffing: There is sufficient staffing at the facility. Administrator Certificate for Hurube Debela-Sledge expires on 08/19/24 and HIV Training Certificate is dated 07/01/22. 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 Facility Administrator and S-1 through S-4. Staff have sufficient on-going training. Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting, Client Rights and Zero Tolerance.

Client Rights-Information: Client personal rights are posted and included in client files. Internet services are provided and paid for by the Facility Administrator. Per Administrator, there is a common area computer station available for clients. Per Administrator, all clients have cell phones. (2) out of (4) have their own personal computer/laptop.

Client Records-Incident Reports: LPA reviewed Client files for C-1 through C-4. Client files are maintained at the facility. Admission Agreement, Functional Capability Assessment, Physician's Report (including T.B 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.

Refer LIC 809C for the continuation of this report.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023

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: DHASA CARE	FACILITY NUMBER: 198603443
	VISIT DATE: 03/17/2023

NARRATIVE

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Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The food is properly stored in the refrigerator (clean and well-maintained). Per S-2, there are no clients on special diets. Pesticides and cleaning supplies are kept away from the food preparation areas (locked under the kitchen sink and inside the garage). 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 are bubbled packed. LPA reviewed medication for C-1 through C-4 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-2, there are no clients at this home with incidental medical services nor have a restricted health condition.

Disaster Preparedness: The facility does not have a complete Emergency Disaster and Mass Casualty Plan. Facility Administrator obtained LIC 610D (9 pages) to complete. Deficiency noted and will be cited on LIC 809D.

Emergency Intervention : Not-Applicable.

Deficiency cited on LIC 809D. Exit interview, appeals rights and a copy of this report was provided to Hurube Debela-Sledge

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/17/2023 02:42 PM - It Cannot Be Edited

Created By: Elizabeth Irra On 03/17/2023 at 12:23 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: DHASA CARE	FACILITY NUMBER: 198603443
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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
1 2 3 4	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.
	POC Due Date: 03/31/2023
	Plan of Correction
1 2 3 4	This standard is not met at evidence by: Facility does not have a complete Disaster and Mass Casualty Plan. Facility Administrator obtained a copy of the LIC 610D form (9 pages to complete). Facility Administrator to complete and submit this plans to LPA Irra by POC due date of 03/31/2023.

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:

Tony Vasallo

LICENSING EVALUATOR NAME:

Elizabeth Irra

LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023

LIC809 (FAS) - (06/04)

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