198603460-6-13-2023-28-AS-EZAA-CSRU38-20230613151306

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603460
Report Date: 06/13/2023
Date Signed: 06/13/2023 03:13:24 PM

Document Has Been Signed on 06/13/2023 03:13 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:	ST. SHARBEL'S GARVEY		FACILITY NUMBER:	198603460
ADMINISTRATOR:	MUNZON, PETER		FACILITY TYPE:	735
ADDRESS:	2007 E GARVEY AVE N		TELEPHONE:	(562) 682-7027
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91791
CAPACITY: 6		CENSUS: 4	DATE:	06/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:59 PM
MET WITH:	Crispo Langa - Caregiver		TIME COMPLETED:	03:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to Crispo Langa, Caregiver at the facility and was granted access into the home. Administrator Peter Munzon was notified by phone of the annual inspection, however he was under the weather and unable to make it to the facility. There are four (4) ambulatory developmentally disabled clients who reside in the home. The facility is vendored through the San Gabriel/Pomona Regional Center.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention.

Infection Control:

· Infection control practices and Personal Protective Equipment (PPEs) were observed. LPA observed that the facility has an Infection Control Plan on file and was advised that it was submitted to CCL a few months ago by administrator over the phone.

Physical Plant/Environment Safety:

· The facility is a single-story home located in a residential neighborhood that is licensed for a capacity of five (5) ambulatory clients and one (1) non-ambulatory client. It consists of three (3) shared client bedrooms of which two (2) are in use, a living room, dining room, a kitchen, two (2) shared client bathrooms of which the non-private restroom R#1 used for staff measured at 107.6 degrees F, the second non-private restroom (R#2) used for clients measured at 108.2 Degrees F, and a third restroom in one of the shared bedrooms (R#3) measured at 109.5 degrees F, a front and back patio area, and a detached garage that includes the facility’s washing and drying machines along with additional non-perishable food supplies.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023

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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Document Has Been Signed on 06/13/2023 03:13 PM - It Cannot Be Edited

Created By: Erik Zaragoza On 06/13/2023 at 02:04 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: ST. SHARBEL'S GARVEY	FACILITY NUMBER: 198603460
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(g)(1)

Building and Grounds

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. 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 4 out of 4 clients because there was an unsecured kitchen knife near the kitchen sink accessible to clients. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/14/2023
	Plan of Correction
1 2 3 4	Administrator/Licensee is to ensure that items that could pose a danger if readily available to clients shall be stored and inaccessible to clients at all times. Staff member Crispo Langa Immediately placed unsecured knife that was located near the kitchen sink in the locked knife cabinet. POC cleared during visit

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:

Erik Zaragoza

LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023

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: ST. SHARBEL'S GARVEY	FACILITY NUMBER: 198603460
	VISIT DATE: 06/13/2023

NARRATIVE

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· The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors are operational. The facility has one (1) fully charged fire extinguisher that is kept in the dining room area. Cleaning supplies and toxic substances are inaccessible to clients in a locked storage area next to the entrance of the facility. However an exposed kitchen knife was found in the kitchen upon entry into the facility.
· Water temperature readings measured between the required 105 - 120 degrees Fahrenheit.
Operational Requirements:
· The Program Design was reviewed.

· Fire clearance was approved by LA County Fire Department for five (5) ambulatory clients and one (1) non-ambulatory developmentally disabled client.

· Care and supervision to meet the clients’ needs was observed.
Staffing:

· A total of three (3) full-time staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

· Administrator certificate is effective through 10/16/2024.

· Three (3) staff files were reviewed for criminal background clearance and training.
· Personnel records have health/TB screenings, CPI training, certifications, and 1st Aid/CPR training.
Client Rights/Information:

· Physician orders were reviewed in client files.

Client Records/Incident Reports:

· Four (4) client files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, nutritional assessments, medication records, and P & I money were reviewed.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023

LIC809 (FAS) - (06/04)

Page: 3 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: ST. SHARBEL'S GARVEY	FACILITY NUMBER: 198603460
	VISIT DATE: 06/13/2023

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Food Service:

· The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.

· Facility has an approved Restricted Health Care plan for the use of a CPAP machine for one client in care.

Health Related Services:

· Clients are assisted with self-administration of prescription and non-prescription medications.

· Four (4) centrally stored resident medication records were reviewed. Centrally stored medications are kept in a safe and locked place not accessible to clients in care. Medications are given according to Physician directions.

Incident Medical and Dental:

· All clients have a Needs and Services Plan, and COVID-19 vaccination cards on file.

· Staff training was on file.

Disaster Preparedness, and Emergency Intervention:

· A posted Emergency Disaster Plan LIC 610D containing emergency evacuation information was observed.

· An emergency drill was last documented and 3/15/2023.

Emergency Intervention:

· No manual restraints or seclusion are used with clients in care.

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: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023

LIC809 (FAS) - (06/04)

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