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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603452
Report Date: 03/10/2022
Date Signed: 03/10/2022 11:03:19 AM

Document Has Been Signed on 03/10/2022 11:03 AM - 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:DHASA CARE IIFACILITY NUMBER:
198603452
ADMINISTRATOR:CARTER, S'HALANAFACILITY TYPE:
735
ADDRESS:757 MILLBURY AVETELEPHONE:
(773) 718-0819
CITY:LA PUENTESTATE: CAZIP CODE:
91746
CAPACITY: 4CENSUS: 3DATE:
03/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:S'Halana Carter; AdministratorTIME COMPLETED:
10:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) David Sicairos conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPA met DSP Noelle Clarke and explained the reason for the visit. Administrator S'Halana Carter arrived shortly thereafter. Physical Plant was toured, sample record of medications were reviewed, and food supply was inspected.

The following was observed/inspected:
  • LPA and Administrator toured the home and inspected (4) client bedrooms, (2) bathrooms, living room, dining room, kitchen, and attached 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 back patio. Passageways and exits are free of obstruction. The water temperature was tested in bathroom #1 (hallway) and measured at 105.5F, water temperature was also measured in bathroom #2 (client bedroom) and measured at 121.8F which is above the required 105F - 120F degrees (Water temperature was adjusted during visit). Client bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have sufficient closet space. Client beds have the required linen and the linen is in good condition. Smoke detectors were observed throughout the facility and were tested and operable during the visit. There is a carbon monoxide detector located in the living room. There are multiple fire extinguishers located throughout the home which are fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked in the hallway and are inaccessible to clients. Cleaning supplies and disinfectants are locked in the hallway 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.
  • Staff were observed wearing masks and screening visitors at entry.
  • Sufficient supply of 2 days perishable & 7 days non-perishable foods were observed.
  • (3) out of the (3) client medications were reviewed. Medications are centrally stored in a cabinet located in the hallway. Medications are documented properly and given as prescribed.
  • 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 deficiency observed during the visit is documented on 809D. Exit interview held and a copy of the report along with appeal rights were provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: David Sicairos
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2022
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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Document Has Been Signed on 03/10/2022 11:03 AM - It Cannot Be Edited


Created By: David Sicairos On 03/10/2022 at 10:35 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: DHASA CARE II

FACILITY NUMBER: 198603452

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 03/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
(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
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Based on physical plant tour, LPA measured water temperature in bathroom #2 and measured at 121.8F. This poses an immediate Health, Safety, and/or Personal Rights risk to the clients in care.
POC Due Date: 03/11/2022
Plan of Correction
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Licensee/Administrator to ensure faucets used by clients for personal care meet Title 22 Regulations at all times. Administrator adjusted water temperature during today's visit. Administrator to submit water log or picture of temperature reading 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:Stefanie Coronel
LICENSING EVALUATOR NAME:David Sicairos
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022


LIC809 (FAS) - (06/04)
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