198603463-8-23-2023-28-AS-CWOG-CUXUPK-20230822154541

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603463
Report Date: 08/22/2023
Date Signed: 08/23/2023 09:10:36 AM

Document Has Been Signed on 08/23/2023 09:10 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	PEPPERDALE HOME		FACILITY NUMBER:	198603463
ADMINISTRATOR:	SCHAEFER, EVELINA		FACILITY TYPE:	735
ADDRESS:	1923 PEPPERDALE DRIVE		TELEPHONE:	(714) 398-4409
CITY:	ROWLAND HEIGHTS	STATE: CA	ZIP CODE:	91748
CAPACITY: 6		CENSUS: 6	DATE:	08/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:05 PM
MET WITH:	Ronald Manalad		TIME COMPLETED:	04:10 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) Wong conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with DSP Edward Dela Cruz and explained the reason of the visit. Shortly after the co-administrator Ronald Manalad arrived and assisted with the visit. The facility is approved for serve Developmentally Disabled Adults, AGE RANGE 18 THROUGH 59. Approved for 6 ambulatory only. The facility is licensed as a 4C home vendored by San Gabriel Pomona Regional Center. The following twelve (12) tool domains were observed and reviewed: Infection Control, Physical Plant/Environmental Safety, Operational Requirements, Staffing, Personal Records-Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incidental Medical Services, Disaster Preparedness and Emergency Intervention. 1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility still encourages hand washing and self symptom check of staff. The facility has an Infection Control Plan and COVID-19 mitigation plan in place. 2. Physical Plant and Environmental Safety: The facility is a single story house and located in a residential neighborhood area. The facility includes: living room, dining area, kitchen, four clients bedrooms, two clients bathrooms, live in staff room, staff office/Clients Activity Area and attached garage. Client bedroom#1 and #4 has one bed, one chair, one night stand, one drawer, required bedding and sufficient lighting and closet space. Bedroom#2 and #3 has two beds, two drawers, required beddings and furniture and sufficient closet space and lighting. The two clients bathrooms are clean and sanitary. The hot water temperature in both bathrooms were tested between 112.4 and 113.9 degrees F which is within the Title 22 regulation. All the appliances in the living room and kitchen are working probably. The sharp knives and utensils are stored and locked in the kitchen drawer. All the cleaning supplies and toxins are stored and locked under the sink.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

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: PEPPERDALE HOME	FACILITY NUMBER: 198603463
	VISIT DATE: 08/22/2023

NARRATIVE

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The facility has a land line telephone system. The hallway light is always on during the night time, so client can have the access to the bathroom. The extra linen are stored in the hallway cabinet and extra personal hygiene products are stored in the storage room in the garage. The walkway, passageway and patio are free of obstruction. LPA also inspected the smoke detectors and carbon monoxide detectors are working probably.

3. Operational Requirement: The facility is licensed for age range 18-59 years old and 6 ambulatory only. Currently all 6 clients are ambulatory. The last fire drill was conducted on 8/1/23 and disaster drill was conducted on 5/31/23. The facility has a shaded area in the backyard with table and chairs for client to utilized the outdoor activity. Clients are able to attend community activities if they want to or if there's any opportunity.

4. Staffing: The facility has a sufficient staffing in the facility. 3 staff in AM shift, 3 in the PM shift and 1 staff in NOC shift. The night shift staff has the required training for planned emergency procedure.

5. Personnel Records-Training: The facility staff files are stored in the cabinet in the staff office/Client Activity Area. The administrator is Evelyn Schaefer and her administrator certificate expired on 10/18/23. The HIV training is updated on 9/9/23 and TB training already expired on 5/24/23. All the staff has the required documents in their files including updated training hours, health screening, TB Test result and First aid certificate. All staff are over 18 years old, criminal background check cleared and associated with the facility.

6. Client's right-Information: The facility does not have any client requires postural support at the present time. The facility does provide at least one internet access device to clients which can support real time interactive application.

7. Client's Records-Incident Reports: The facility client files are stored in the cabinet in the staff office/Client activity area. All the clients files have the required documents in their files which are included: face sheet, admission agreement, functional capability assessment, Individual Program Plan (IPP), medication list, ambulatory status and updated Physician Report and TB test result.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

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: PEPPERDALE HOME	FACILITY NUMBER: 198603463
	VISIT DATE: 08/22/2023

NARRATIVE

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8. Food Service: Currently no client is required modified diet in the facility. The facility has sufficient food supply including two days perishable and seven days non perishable food. The facility has two refrigerators, one in the kitchen and one in the garage for additional food storage. The additional canned goods/emergency food supply also stored in the storage room in the garage. All the food is stored probably. The refrigerators are maintained with the required temperature.

9.Health Related Services: The medication is stored and locked in the medication cabinet near the entry way. LPA inspected six (6) clients medication and Medication Administration Record (MARs) and they all seemed accurate and updated.

10. Incidental Medical Services: The facility currently does not have any clients with Prohibited Health Condition or Restricted Health Condition.

11. Disaster Preparedness: The facility has an updated emergency disaster plan (LIC610D) dated on 4/1/23. The last disaster drill was conducted on 5/31/23. The facility always has two available temporary shelter location.

12. Emergency Intervention: The facility does not use restraint on clients but all staff has the updated CPI training in file.

No deficiencies were observed during the visit.

Exit Interview held. The copy of the repot was provided to Co-Administrator Ronald Manalad

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC809 (FAS) - (06/04)

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