198603452-3-19-2024-28-AS-NMAN-D3HVA6-20240319161525

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603452
Report Date: 03/19/2024
Date Signed: 03/19/2024 04:15:32 PM

Document Has Been Signed on 03/19/2024 04:15 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:	DHASA CARE II		FACILITY NUMBER:	198603452
ADMINISTRATOR:	CARTER, S'HALANA		FACILITY TYPE:	735
ADDRESS:	757 MILLBURY AVE		TELEPHONE:	(626) 257-3574
CITY:	LA PUENTE	STATE: CA	ZIP CODE:	91746
CAPACITY: 4		CENSUS: 3	DATE:	03/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:07 PM
MET WITH:	Anthony Okwudi		TIME COMPLETED:	04:20 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) Nune Margaryan conducted an unannounced annual visit using the Care Tool. LPA met with staff Anthony Okwudi who assist with the visit. LPA explained the reason for the visit. Administrator Carter S'Halana arrived around 2:30 pm.

This is a single-story home located in a residential neighborhood and consists of the following:

This home consists of (4) bedrooms, (2) bathrooms, living room, kitchen, dining area and attached garage. Laundry observed in the garage. The facility is approved for four (4) ambulatory developmentally disabled adults, ages 18-59. There are currently three (3) clients residing in this facility and receive services from San Gabriel/Pomona Regional Center.

The front and backyard are well maintained and there are no pools or large bodies of water. Passageways and exits are free of obstruction. There is a shaded sitting area in the back of facility. Client bedrooms and bathrooms were checked. Each bedroom is equipped with the proper furnishings. Bedrooms also have sufficient closet space. The bathrooms are clean and have the required hygiene items. The hot water temperature was tested and was measured at 103.2 degrees F. Extra linens, blankets, towels, and personal hygiene supplies were observed. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and working properly. Sharps are locked and are inaccessible to clients. Hot water temperature tested in the kitchen and was measured at 122.3 degree F. LPA observed laundry detergent, cleaning solutions/disinfectants are stored and locked in the hallway cabinet. 2 fire extinguishers observed in the garage and in the kitchen fully charged. Carbon monoxide/smoke detectors in the hallway / living room and in the client rooms are operational.

Continued 809C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

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 03/19/2024 04:15 PM - It Cannot Be Edited

Created By: Nune Margaryan On 03/19/2024 at 02:55 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 II	FACILITY NUMBER: 198603452
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. In the clients bathroom the hot water was measured at 103.2 degree F and in the kitchen measured 122.3 degree F, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/19/2024
	Plan of Correction
1 2 3 4	Water temperature was adjusted at the time of visit. The licensee will ensure that the hot water temperature is maintained between 105 degrees F - 120 degrees F as required.

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:

Wei Siew Ho

LICENSING EVALUATOR NAME:

Nune Margaryan

LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 II	FACILITY NUMBER: 198603452
	VISIT DATE: 03/19/2024

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
26
27
28
29
30
31
32

The First Aid kit was fully stocked with all required items including a current manual. Centrally stored medications are stored in a locked cabinet in the hallway. LPA reviewed clients and staff files. LPA confirmed staff working have fingerprint clearances. LPA reviewed clients medications. Medications are documented properly and given as prescribed.

Observed deficiency is documented on 809D.

Exit interview conducted with Administrator and the copy of the report and appeal rights are provided.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3