<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603463
Report Date: 07/12/2024
Date Signed: 07/12/2024 06:00:42 PM

Document Has Been Signed on 07/12/2024 06:00 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:PEPPERDALE HOMEFACILITY NUMBER:
198603463
ADMINISTRATOR/
DIRECTOR:		SCHAEFER, EVELINAFACILITY TYPE:
735
ADDRESS:1923 PEPPERDALE DRIVETELEPHONE:
(714) 398-4409
CITY:ROWLAND HEIGHTSSTATE: CAZIP CODE:
91748
CAPACITY: 6CENSUS: 6DATE:
07/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:10 PM
MET WITH:Sally Balto, StaffTIME VISIT/
INSPECTION COMPLETED:
04:30 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) Cynthia Chan conducted the required annual inspection using the Compliance and Regulatory Enforcement (CARE) tool. LPA arrived unannounced and met with Staff, Sally Balto. The facility is licensed for (6) ambulatory adults, ages 18 - 59.

LPA toured the facility, reviewed files, and conducted interviews. The following were observed:
The facility does not have any pools or bodies of water on the premises. There are 4 client bedrooms, 1 staff room, 2 bathrooms, living room, kitchen, staff/client activity area, and attached garage. The clients bedrooms have the required furniture and storage space. Bedroom #2's window has an opening below the window frame and a hole was observed on the window screen. There are extra linens and hygiene supplies. Facility has an operable smoke detector in each room and a carbon monoxide detector. Knives and cleaning solutions are locked. The hot water temperature was measured between the required range of 105-120 degrees F. The facility is operating within the fire clearance approval. Staff are continuing to follow their infection control plan. LPA observed sufficient food supplies of 2 day perishable and a week of non-perishable items. Foods are properly stored in the refrigerator to avoid contamination.
LPA reviewed records for 3 Staff and 6 Clients. Staff are all fingerprint cleared and associated to the facility. Staff and Client files all have the required documents. Staff have current first aid and CPR training. They do not utilize manual restraints at the home. Medications are centrally stored and locked in the hallway storage room. LPA reviewed medications for all 6 clients and there was a discrepancy noted for Client #3. The facility has the updated emergency and disaster plan and is conducting monthly fire drills and disaster drills.
Deficiencies are issued on the LIC809D page. An exit interview was held and a copy of this report was given to the staff.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2024
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 07/12/2024 06:00 PM - It Cannot Be Edited


Created By: Cynthia D Chan On 07/12/2024 at 03:40 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: PEPPERDALE HOME
FACILITY NUMBER: 198603463

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80065(a)
80065 Personnel Requirements
(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and observation, the licensee did not comply with the section cited above in 1 out of 6 clients' medication (Metformin HCL 500 MG - PM) was still in the bubble pack dated 7/11/24, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/13/2024
Plan of Correction
1
2
3
4
The licensee shall ensure medications are administered as prescribed. An in-service training is to be given to all staff handling medications and the log shall be submitted to LPA by 7/13/24.
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:Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/12/2024 06:00 PM - It Cannot Be Edited


Created By: Cynthia D Chan On 07/12/2024 at 04:15 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: PEPPERDALE HOME
FACILITY NUMBER: 198603463

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in which bedroom #2's window has an opening below the edge and a hole was observed in the screen, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2024
Plan of Correction
1
2
3
4
The licensee shall repair the window to prevent bugs/insects from entering the facility. The POC shall be submitted to LPA by 7/26/24.
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:Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2024


LIC809 (FAS) - (06/04)
Page: 3 of 3