198603474-9-14-2023-28-AS-CWOG-CVNVLB-20230914163141

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603474
Report Date: 09/14/2023
Date Signed: 09/14/2023 05:53:01 PM

Document Has Been Signed on 09/14/2023 05:53 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:	HELIO		FACILITY NUMBER:	198603474
ADMINISTRATOR:	MARCELO, TAJ		FACILITY TYPE:	735
ADDRESS:	510 FOXPARK DRIVE		TELEPHONE:	(929) 429-0836
CITY:	POMONA	STATE: CA	ZIP CODE:	91767
CAPACITY: 4		CENSUS: 4	DATE:	09/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Yanet Saidana		TIME COMPLETED:	05:00 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 Aura Alarcio and Yanet Saidana and explained the reason of the visit. The facility is approved for serve Developmentally Disabled, age range 18-59 and 4 ambulatory only. The facility is licensed as a 4I 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. The facility has an Infection Control Plan and COVID-19 mitigation plan in place. 2. Physical Plant/Environmental Safety: The facility is a single story house and located in a residential neighborhood area. The facility includes living room, kitchen, dining area, staff office, four clients bedrooms, two clients bathrooms and an attached garage. Each client room has one bed, one chair, one night stand, one drawer and required beddings and sufficient lighting and closet space. The two clients' bathrooms are clean, sanitary and in a workable condition. The hot water temperature in two clients bathrooms are tested 105 degrees F which are within Title 22 regulation. All the sharp knives, utensils, chemicals and cleaning supplies are stored and locked under the sink. All the appliances in the kitchen and living room are working well. LPA inspected smoke detectors and carbon monoxide detectors are all working probably. The extra personal hygienes are stored in the garage. The extra linen and towels are stored in the hallway closet. The facility would turn on the hallway light at night so client can passage to nonprivate bathrooms. The facility has a land-line telephone system.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

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: HELIO	FACILITY NUMBER: 198603474
	VISIT DATE: 09/14/2023

NARRATIVE

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3.Operational Requirements: The facility is licensed for four (4) ambulatory and currently all clients in the facility are ambulatory. The facility would also allow clients to attend community activities if there's a chance or opportunity. The facility has a shaded area in the patio with table and chairs for client to utilize the outdoor activity.

4.Staffing: The facility has sufficient staffing in the facility. LPA reviewed the NOC shift staff and the staff has required planned emergency procedure training.

5. Personnel Records-Training: The staff files are stored in the locked file cabinet in the staff office. All staff are over 18 years old, criminal background clearance and associated to the facility. LPA reviewed the staff file, they all have updated First Aid Certificate and required training hours. The facility administrator is Taj Marcelo and her administrator certificate expired 12/15/2024 and she also has an updated HIV and TB Training

6. Client Right-Information: No client in the facility required postural support. The facility does have internet service and serve client with at least one access device if needed.

7. Client records-Incident Reports: All client staff files are stored in the locked file cabinet in the staff office. All clients has the required documents included face sheet, admission agreement, Individual Program Plan (IPP), updated physician report and TB Test result, functional capabilities assessment, ambulatory status and medication list

8. Food service; No client in the facility is on any modified diet. The facility have sufficient food supply for two days perishable and 7 days non perishable which stored in the refrigerator in the kitchen and the garage and kitchen cabinet. All the food are stored probably.

9. Health Related Services: All the clients medication are centrally stored and locked in the cabinet in the staff office. LPA inspected all four (4) clients' medication and all are updated and accurate and all clients received 30 days supply of medication.

10. Incidental Medical Services: Currently no client in the facility has prohibited health condition. Facility has one client is currently under restricted health condition care. The client does have a updated restricted health condition plan in file and each staff has the required and updated training related to restricted health condition in file too.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

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: HELIO	FACILITY NUMBER: 198603474
	VISIT DATE: 09/14/2023

NARRATIVE

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11. Disaster Preparedness: The facility does not have an updated disaster plan and last one was completed on 3/23/21. The last emergency drill was conducted on 3/15/23.

12. Emergency Intervention: The facility does not use any restraint on clients but all staff does have the required CPI training every two years.

Per California Code of Regulations, Title 22, deficiencies were cited.

Exit interview was conducted with Yanet Saidana. A copy of the report and appeal rights were issued.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 09/14/2023 05:53 PM - It Cannot Be Edited

Created By: Christine Wong On 09/14/2023 at 04:08 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: HELIO	FACILITY NUMBER: 198603474
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1565(d)

1565 (d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee, administrator, or regulated individual shall sign and date the documentation to indicate that the plan has been reviewed and updated as necessary. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the facility does not have an updated emergency diaster plan in the facility and the last one was completed on 3/23/21 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/28/2023
	Plan of Correction
1 2 3 4	The administrator will updated the emergency disaster plan (LIC610) and send to LPA by POC due date.

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:

Christine Wong

LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

LIC809 (FAS) - (06/04)

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