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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603509
Report Date: 05/01/2023
Date Signed: 05/01/2023 02:12:08 PM

Document Has Been Signed on 05/01/2023 02:12 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:ABS FILMORE RESIDENTIALFACILITY NUMBER:
198603509
ADMINISTRATOR:ROJAS, DIANAFACILITY TYPE:
735
ADDRESS:658 FILMORE PLTELEPHONE:
(909) 455-8159
CITY:POMONASTATE: CAZIP CODE:
91766
CAPACITY: 4CENSUS: 3DATE:
05/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Diana RojasTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elizabeth Irra conducted the required annual inspection. LPA was allowed entry by Norman “Allen” Metzner (S-1). LPA explained the purpose of today's visit. Diana Rojas (Administrator) arrived at approximately 9 A.M..

This is a single story home which consists of (3) bedrooms, (2) bathrooms, living room, kitchen and dining area. All Clients residing at this facility receive case management services provided by San Gabriel Pomona Regional Center.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has sufficient PPE supplies. Bathrooms have hand washing signs, soap and paper towels. Staff are adhering to infection control requirements.

Operational Requirements: The fire clearance is approved for (4) ambulatory clients. Last Fire Drill and Earthquake Drill were conducted 02/24/23. Staff are adhering to operational requirements.

Refer to LIC 809C for the continuation of this report.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 05/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2023
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 6
Document Has Been Signed on 05/01/2023 02:12 PM - It Cannot Be Edited


Created By: Elizabeth Irra On 05/01/2023 at 11:22 AM
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: ABS FILMORE RESIDENTIAL
FACILITY NUMBER: 198603509

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. Facility did not have (1) week of non-perishable food supply.
POC Due Date: 05/01/2023
Plan of Correction
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Administrator purchased additional non-perishable food supply and corrected deficiency prior to LPA Irra's departure.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2023


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 05/01/2023 02:12 PM - It Cannot Be Edited


Created By: Elizabeth Irra On 05/01/2023 at 11:22 AM
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: ABS FILMORE RESIDENTIAL
FACILITY NUMBER: 198603509

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(k)
Administrator Qualifications and Duties
(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and administrator confimation, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. HIV and TB training Certificate for Diana Rojas (Administrator) was dated 06/17/2020. Per Administrator, she has not taken an updated training after 06/17/2020.
POC Due Date: 05/08/2023
Plan of Correction
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Administrator to submit proof of HIV and TB training registrator to LPA Irra by POC due date noted above.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2023


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 05/01/2023 02:12 PM - It Cannot Be Edited


Created By: Elizabeth Irra On 05/01/2023 at 11:37 AM
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: ABS FILMORE RESIDENTIAL
FACILITY NUMBER: 198603509

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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80072 Personal Rights (a)(8)(F): (a)Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (8) Not to be placed in any restraining device. Postural supports may be used under the following conditions: (F) Protective devices including, but not limited to, helmets, elbow guards, and mittens which do not prohibit a client's mobility but rather protect the client from self-injurious behavior are not to be considered restraining devices for the purpose of this regulation. This standard is not met as evidence by: C-2 was observed wearing a protective helmet due to a medical condition without an exemption from CCLD.
POC Due Date: 05/08/2023
Plan of Correction
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Administrator to obtain documentation from C-2’s physician and regional center in regards to C-2 wearing a helmet due to seizures. Administrator to submit a request to CCL LPA for an exception for C-2. 1).All requests to use protective devices shall be in writing and include a written order of a physician indicating the need for such devices. The licensing agency shall be authorized to require additional documentation including, but not limited to, the Individual Program Plan (IPP) as specified in Welfare and Institutions Code Section 4646, and the written consent of the authorized representative, in order to evaluate the request. 2. The licensing agency shall have the authority to grant conditional and/or limited approvals to use protective devices.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2023


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: ABS FILMORE RESIDENTIAL
FACILITY NUMBER: 198603509
VISIT DATE: 05/01/2023
NARRATIVE
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Physical Plant & Environment Safety: Smoke alarms were tested and operable. Fire extinguisher is located in the living room and appeared to be full. Carbon monoxide was located in the living room (tested and operable). Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. There are no firearms or weapons stored at the facility. Hot water supply measured: Kitchen 115.5*. Bathrooms: 118.5*.

Staffing: There is sufficient staffing at the facility. Administrator Certificate for Diana Rojas expires on 09/21/2023. HIV Certificate is dated 06/17/2020. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator and S-1 through S-3. Staff have sufficient on-going training. Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting, Client Rights and Zero Tolerance.

Client Rights-Information: Client personal rights are posted and included in client files.

Client Records-Incident Reports: LPA reviewed Client files for C-1 through C-3. Client files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment, Individual Program Plan (IPP), Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights observed.

Food Service: There are sufficient food supplies of 2-day perishable. A week of non-perishable items was not observed during the visit. However, Administrator ordered non-perishable food supply prior to LPAs departure. The food is properly stored in the refrigerator. Per Administrator, there are no clients on special diets. Pesticides and cleaning supplies are kept away from the food preparation areas (locked inside a cabinet). Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.

Refer to LIC 809C for the continuation of this report.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6
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: ABS FILMORE RESIDENTIAL
FACILITY NUMBER: 198603509
VISIT DATE: 05/01/2023
NARRATIVE
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Health Related Services The medications are centrally stored and in their original containers. Medications are bubbled packed and stored inside a locked cabinet inside the office. LPA reviewed medication for C-1 through C-3. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician.

Incidental Medical Services: Per Administrator, there are no clients at this home with a restricted health condition. C-2 was observed wearing a protective helmet due to a medical condition without an exemption from CCLD. LPA cited deficiency under 80072 (a)(8)(f) and provided a copy of this regulation to Administrator.

Disaster Preparedness: The facility has an Emergency Disaster Plan.

Deficiencies cited. Exit interview, appeals rights and a copy of this report was provided to Diana Rojas.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023
LIC809 (FAS) - (06/04)
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