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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603525
Report Date: 09/12/2024
Date Signed: 09/12/2024 02:04:35 PM

Document Has Been Signed on 09/12/2024 02:04 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:LAMBERT PLACE, THEFACILITY NUMBER:
198603525
ADMINISTRATOR/
DIRECTOR:		ALVAREZ, EDUARDOFACILITY TYPE:
737
ADDRESS:13304 LAMBERT RDTELEPHONE:
(909) 631-8521
CITY:WHITTIERSTATE: CAZIP CODE:
90602
CAPACITY: 3CENSUS: 3DATE:
09/12/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Ashish Bhavsar, LicenseeTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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A Non-Compliance Conference meeting was held at the Monterey Park Adult and Senior Care Licensing Office. Regional Manager Araceli Ramirez, Licensing Program Manager Lisa Hicks, and Licensing Program Analyst Noemi Galarza met with Deesha Inc Licensee, Ashish Bhavsar, Administrator Eduardo Alvarez, Lead RBT Adriana Harbin California Department of Developmental Services (DDS), Catherine Knight, Assistant Deputy Director, Leah O'Meara, Behavior Specialist II and Eastern Los Angeles Regional Center (ELARC) Elizabeth Harrell, Manager of Community Services, Anna Aguilar, Consumer Services Supervisor, Jesus Ozeda, QA/Compliance Supervisor, Rhoda Tong, Associate Chief of Consumer Services, Araceli Anguiano, QA Specialist.

The purpose of the meeting was to discuss areas not met during DDS Semi-annual review (7/22/2024 & 7/25/2024) and issuance of a Corrective Action Plan by ELARC that addresses substantial inadequacies. DDS findings revealed that 27 staff were overdue in renewal of emergency intervention training, QA reports not maintained in the facility, Registered Behavior Technician (RBT) certification not obtained within 12 months of hire, on-site training, consultant hours not met, emergency intervention documentation and reporting, and staffing requirements. In addition, personnel issues regarding on-going complaints of inappropriate workplace relationships were discussed.

Licensee was provided a copy of the Non-Compliance Conference Summary, and expressed interest in the CCLD Technical Support Program.

Per Title 22, deficiencies are cited.

Exit interview was conducted with Licensee Ashish Bhavsar. A copy of this report and appeal rights were issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2024
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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Document Has Been Signed on 09/12/2024 02:04 PM - It Cannot Be Edited


Created By: Noemi Galarza On 09/12/2024 at 08:02 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: LAMBERT PLACE, THE
FACILITY NUMBER: 198603525

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/03/2024
Section Cited
CCR
89965(b)(2)

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Personnel Requirements. The licensee shall ensure that each direct care staff person meets the following qualifications: Become a Registered Behavior Technician within twelve (12) months of initial employment.

This requirement was not met evidenced by:
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Licensee agrees to ensure all direct care staff obtain RBT certification within their initial 12 months of employment.

Submit in writing how this deficiency has been addressed.
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Based on DDS semi-annual review conducted on 7/22/24 & 7/25/24, the findings indicate 3 out of 27 direct care staff did not obtain RBT certification within their initial 12 months of hire (staff were overdue by less than 30 days). This poses a potential health and safety risk to persons in care.
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Type B
10/03/2024
Section Cited
CCR89965(i)

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Personnel Requirements. In addition to any other required training, each direct care staff person shall have a minimum of 16 hours of emergency intervention training per Section 1567.64 of the Health and Safety Code, which shall include the techniques the licensee will use to prevent injury and maintain safety regarding clients who are a danger to self or others and shall emphasize positive behavioral supports and techniques that are alternatives to physical (manual) restraints, pursuant to the following:
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Licensee agrees to ensure all staff receive 16 hours of emergency intervention training by a qualified instructor within 80 hours of employment, and 16 hours of training annually. A minimum of 20 minute monthly emergency intervention refresher trainings shall be provided by qualified staff.
Submit proof that all direct care staff have completed emergency intervention training.
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This requirement was not met evidenced by:
On 7/22/24 & 7/25/24 during the DDS semi-annual review, it was observed that based on ELARC QA review, 25 staff had not completed 16-hours of emergency intervention training, as staff were due for recertification between March 2024- July 2024
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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:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/12/2024 02:04 PM - It Cannot Be Edited


Created By: Noemi Galarza On 09/12/2024 at 08:02 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: LAMBERT PLACE, THE
FACILITY NUMBER: 198603525

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/19/2024
Section Cited
CCR
89965(g)

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Personnel Requirements. In addition to the hours required in subsection (e), the facility administrator shall ensure a provision of a minimum of 6 consultant hours per month per client, which shall be appropriate to meet individual client service needs. This requirement was not met evidenced by:
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Licensee agreed to ensure the provision of a minimum of 6 consultant hours per month, per client are logged, reported, and documentation is maintained for monitoring agency review.

Submit a written plan of correction, and a log of consultant hours of all clients in care.
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Based on DDS semi-annual review conducted on 7/22/24 & 7/25/24, the findings indicate a minimum of 6 hours per month of consultation services could not be verified for 1 out of 3 clients. It was noted only 2 hours of Psychiatry consultation services in Feb. 2024. This poses a potential health and safety risks to persons in care.
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Type B
09/19/2024
Section Cited
CCR80066(f)

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Personnel Records. In all cases, personnel records shall document the hours actually worked.

This requirement was not met evidenced by:
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Licensee agrees to ensure updates are made to reflect actual hours worked by all facility staff.

Submit a written plan of correction that includes implemented procedures, and staffing schedules.
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Based on DDS semi-annual review conducted on 7/22/24 & 7/25/24, the findings indicate that schedules did not reflect actual hours Administrator and Assistant Administrator worked, and if any lead or direct care shifts were covered. This poses a potential health and safety risk to persons in care.
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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:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 09/12/2024 02:04 PM - It Cannot Be Edited


Created By: Noemi Galarza On 09/12/2024 at 08:03 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: LAMBERT PLACE, THE
FACILITY NUMBER: 198603525

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/19/2024
Section Cited
CCR
85161(c)

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Emergency Intervention Documentation and Reporting Requirements. The report in Section 85161(b) above must include the following:

This requirement was not met evidenced by:
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Licensee shall ensure Administration staff report all emergency intervention and manual restraint incidents no later than the next business day, and the report has detailed description of the incident.

Submit a written plan of correction and proof of staff training.
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Based on DDS semi-annual review conducted on 7/22/24 & 7/25/24, the findings indicate that on 3/28/24 ELARC issued a Corrective Action Plan for failure to report special incident reports, and conditions posing a threat. This poses a potential health and safety risk to persons in care.
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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:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024


LIC809 (FAS) - (06/04)
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