198603528-1-27-2024-28-AS-THEA-CZVTV7-20240127140328

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603528
Report Date: 01/27/2024
Date Signed: 01/27/2024 02:03:35 PM

Document Has Been Signed on 01/27/2024 02:03 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:	WARVALE FACILITY		FACILITY NUMBER:	198603528
ADMINISTRATOR:	HERNANDEZ, YESSICA		FACILITY TYPE:	735
ADDRESS:	8740 WARVALE ST.		TELEPHONE:	(323) 346-3450
CITY:	PICO RIVERA	STATE: CA	ZIP CODE:	90660
CAPACITY:	4	CENSUS: 2	DATE:	01/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Edgar Hernandez - Administrator		TIME COMPLETED:	02:00 PM

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Licensing Program Analyst (LPA) Tena Herrera conducted the required unannounced annual inspection. LPA met with Edgar Hernandez (Administrator) and explained the reason for the visit. The facility is licensed to serve 4 non-ambulatory clients ages 18-59. Facility currently has 2 non-ambulatory clients serviced by Eastern Los Angeles Regional Center.

The facility is a single-story home located in a residential area in Pico Rivera, Ca. A tour of the facility includes: living room, dining room, kitchen, 1 client bathroom, 1 staff bathroom (within staff bedroom), 2 client bedrooms, 1 staff bedroom, attached garage, front yard, back yard and locked tool shed.

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility.

Physical Plant & Environment Safety: LPA toured facility, clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested throughout the facility and measured within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked and are inaccessible to clients. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged.
Operational Requirements: Staff have proper training to meet the needs of the clients in care. Facility has an activity area furnished for outdoor use. Last fire/earthquake drill was conducted in January 2024.
Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the clients in the case of an emergency.
(Continued on 809-C)

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2024

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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Document Has Been Signed on 01/27/2024 02:03 PM - It Cannot Be Edited

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: WARVALE FACILITY	FACILITY NUMBER: 198603528
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80075(b)(6)(D)(2)

80075 Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (6) If the client is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (D) For every prescription and nonprescription PRN medication for which the licensee provides assistance, there shall be a signed, dated written order from a physician on a prescription blank, maintained in the client's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. (2) The exact dosage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in as client #1 was missing a pm dosage of medication on 1/26/24, staff initialed MAR stating that client was administered medication but medication was found loose and inbetween other bubble pack medications, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/28/2024
	Plan of Correction
1 2 3 4	Administrator to contact primary physician today, advise physician of missed medication and follow instructions. Once done Administrator to submit SIR to licensing with client information and outcome from physician with name of medication and dosage missed. Further, Administrator will to provide an in-service training on medication administration and submit training information to LPA via email by 1/28/24, and training log with participant signature to be submitted to LPA via email by 2/12/2024.

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	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2024

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: WARVALE FACILITY	FACILITY NUMBER: 198603528
	VISIT DATE: 01/27/2024

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Personnel Records-Training: Staff files are maintained in the main office (offsite). LPA reviewed 4 staff files during today’s visit, files reviewed contained the following: current First Aid/CPR/AED and sufficient on-going training. Administrators Edgar Hernandez certificate expires 1/27/24 and Yessica Hernadez expires 9/7/24.
Client Rights-Information: Facility provides telephone landline for the clients. Client rights posters and reporting posters are displayed throughout facility.
Client Records-Incident Reports: Client files are maintained in the locked cabinet and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. LPA reviewed 2 client files with no issues.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Note that all clients at facility are on liquid diets, sufficient amount of liquid foods were observed.
Health Related Service: Staff designated to administer medication have the proper annual training on file. Medication is properly labeled and are centrally stored in a closet and are in their original containers. LPA reviewed 2 client’s medications during todays visit and resident # 1 had a missed dosage of medication, details will be documented on the 809-D.
Incidental Medical & Dental: All training is documented in the facility personnel files. Staff performance is reviewed annually, and documentation is maintained in the personnel files.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Facility maintains documentation of the required emergency drills, with the last drill conducted in January 2024.
Emergency Intervention: Clients at this facility have not needed the use of restraints or the use de-escalation techniques.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on 809D.

Exit interview was held and a copy of the report and appeal rights were provided to Administrator Edgar Hernandez.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2024

LIC809 (FAS) - (06/04)

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