198603491-2-27-2024-28-AS-CWOG-D2V28R-20240227161047

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603491
Report Date: 02/27/2024
Date Signed: 02/27/2024 04:12:05 PM

Document Has Been Signed on 02/27/2024 04:12 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:	COVENANT CARE HOME		FACILITY NUMBER:	198603491
ADMINISTRATOR:	AMANYA, HERBERT BAGORO		FACILITY TYPE:	735
ADDRESS:	2027 SHAMWOOD ST		TELEPHONE:	(818) 571-2247
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91791
CAPACITY: 4		CENSUS: 4	DATE:	02/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Bundi Nyaga		TIME 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) Wong conducted the unannounced Annual Inspection and met with Administrator Bundi Nyaga who allowed the entry of the facility and explained the reason of today's visit and will be using the Compliance And Regulatory Enforcement (CARE) Tools to inspect the facility. The facility is licensed for age range 18 through 59 and ambulatory only. The facility is vendorized as Level 4C Medical home with San Gabriel Pomona Regional Center. The following domains were reviewed during today's annual required visit which included: infection control, physical plant and environmental, operational requirements, staffing, personnel 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 Plan: The facility staff practice hand washing and using gloves in the facility. Staff would clean and disinfect once a day and more often for high touched surfaces area. Facility has sufficient PPE supplies. 2. Physical Plant and Environmental Safety: The facility is a single story house and located in a residential neighborhood area. The facility includes: kitchen, living room, staff work area, dining area, three clients bedrooms, staff bathroom, one client bathroom, laundry room and an attached garage. Bedroom#1 has two beds, two chairs, two drawers, required furniture and beddings and sufficient lighting and closet space. Bedroom#2 and #3 has one bed, one chair, one night stand, one drawer, required furniture and bedding and sufficient closet space and lighting. The client bathroom is clean, sanitary and in a good working condition. The hot water temperature tested between 105 and 112.4 degrees F which is within the Title 22 regulation. All the kitchen appliances are working properly. All the sharp knives are stored and locked in the kitchen drawer and all the cleaning supplies are stored and locked under the sink. The hallway light is on during night time, so client can have access to the non-private bathrooms. The extra personal hygiene products are stored in the hallway cabinet.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

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: COVENANT CARE HOME	FACILITY NUMBER: 198603491
	VISIT DATE: 02/27/2024

NARRATIVE

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The extra linen and towels are stored in the hallway cabinet next to the bathroom. Facility has a telephone service on the premises. The passageway, walkway and backyard are free of obstruction. LPA inspected the carbon monoxide detectors and they are all working well.

3. Operational Requirement: Currently all the clients are ambulatory and they are within the requirement from the fire inspection. The facility would support client to participate community activities if there's a chance. The facility has a shaded area with table and chairs for client to utilize the outdoor activity.

4. Staffing: The facility has sufficient staffing in the facility. The NOC shift staff has the updated facility planned emergency procedure training.

5. Personnel Records: All the staff files are stored in the file cabinets. All the facility staff are over 18 years old with background check cleared and associated with the facility. LPA inspected three staff files and they all have the required documents in files: Health screening, TB Test result, updated first aid certificate and required training hours. The facility administrator is Bundi Nyaga and his administrator certificate expiration date on 12/27/24 and the administrator has the required and updated HIV and TB training certificate.

6. Client's Right: The facility does not have any client with postural support at the present time. The facility would provide internet service with internet access device for client to communicate with their families or day program or their medical professional.

7.Food Service: No client in the facility is on any modified diet that prescribed by the doctor. The facility has ample supply for two days perishable and seven days non-perishable food supply in the facility. All the food in the facility are stored properly.

8. Client's Records and Incident Reports: The client's files are stored in the file cabinet near the living room. LPA inspected all four client files and they all have the required documents included: face sheet, functional capacity assessment, admission agreement, updated physician report and Individual Program Plan (IPP), medication list and ambulatory status.

9. Health Related Services: All the clients medication are centrally stored and locked in the file cabinet near the living room. LPA inspected all four client's medication and they are all seemed updated and accurate. All four client have the 30 days supply of medication. The facility would provide arrangement for client's medical and dental appointment. LPA inspected the first aid supplies and they have all the required supplies.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

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: COVENANT CARE HOME	FACILITY NUMBER: 198603491
	VISIT DATE: 02/27/2024

NARRATIVE

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10. Incidental Medical Services: The facility does not have any client with restricted health condition plan and they are not retaining any client with prohibited health condition.

11. Disaster Preparedness: The facility does not have an updated emergency disaster plan (LIC610D) and the last one was updated on 3/22/22. The last fire/disaster drill was conducted on 12/24/23. The facility has two temporary alternative shelter location.

12. Emergency Intervention: The facility does not use any restraints on clients.

LPA provided a technical assistance on infection control plan and Emergency Disaster Plan. A copy of this report was given to the Administrator.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

LIC809 (FAS) - (06/04)

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