198603528-3-21-2025-28-AS-EZAA-DEYUTC-20250321155142

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603528
Report Date: 03/21/2025
Date Signed: 03/21/2025 03:52:24 PM

Document Has Been Signed on 03/21/2025 03:52 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/ DIRECTOR:	HERNANDEZ, YESSICA		FACILITY TYPE:	735
ADDRESS:	8740 WARVALE ST.		TELEPHONE:	(323) 346-3450
CITY:	PICO RIVERA	STATE: CA	ZIP CODE:	90660
CAPACITY: 4		CENSUS: 3	DATE:	03/21/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:46 PM
MET WITH:	Maria Hernandez - Caregiver		TIME VISIT/ INSPECTION COMPLETED:	04:17 PM

NARRATIVE

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Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1-year visit using the full Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Maria Hernandez, caregiver for the facility, and explained the purpose of the visit. Administrator Edgar Hernandez arrived shortly thereafter. There are three (3) ambulatory clients residing in the facility.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention.

Infection Control:

· Infection control practices were observed. LPA observed that the facility has a completed infection control plan.

Physical Plant/Environment Safety:

· The facility is a single-story home located in a residential neighborhood that is licensed for a capacity of four (4) ambulatory clients between the ages of eighteen (18) through fifty-nine (59). It consists of three (3) client bedrooms, a kitchen, a living room, a dining room, an attached garage that contains extra supplies for the facility, a backyard with shaded area with a locked storage shed that contains tools, and a client restroom which had a hot water temperature reading of 108.8 Degrees Fahrenheit. Knives along with the chemicals and cleaning supplies are kept locked and inaccessible to clients.

· The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. There are no pools are or bodies of water accessible to the clients. Fire alarm system and carbon monoxide detectors are operational. The facility has two (2) fully charged fire extinguishers that are kept throughout the facility. Cleaning supplies and toxic substances are kept locked and inaccessible to clients.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025

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 03/21/2025 03:52 PM - It Cannot Be Edited

Created By: Erik Zaragoza On 03/21/2025 at 03:29 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: WARVALE FACILITY	FACILITY NUMBER: 198603528
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/21/2025

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
1 2 3 4	Based on record review and interview, the licensee did not comply with the section cited above in 1 out of 5 staff members, because the administrator did not have documented retraining on HIV and TB within the past 2 years, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/18/2025
	Plan of Correction
1 2 3 4	Licensee/Administrator is to ensure that the administrator receives retraining on the topics of HIV for 3 hours and TB for 1 hour once every 2 years. Administrator is to have retraining on these subjects, obtain record of the training, and email the certificates of the retraining to the LPA by the 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:

Erik Zaragoza

LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025

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: 03/21/2025

NARRATIVE

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Operational Requirements:

· The Program Design was reviewed.

· Fire clearance was approved by LA County Fire Department for four (4) ambulatory clients between the ages of 18 – 59.

· Care and supervision to meet the clients’ needs was observed.

Staffing:

· A total of ten (10) full-time staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

· Administrator’s certificate expires on 1/28/2026.

· Five (5) staff files were reviewed for criminal background clearance and training.
· Personnel records have health/Tuberculosis (TB) screenings, certifications, and 1st Aid/CPR training.
· Administrator did not have the retraining that is required every two (2) years on the subjects of HIV and Tuberculosis (TB) on record.

Client Rights/Information:

· Physician orders were reviewed in client files.

Client Records/Incident Reports:

· Five (5) client files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, nutritional assessments, medication records, and Personal and Incidental (P & I) money were reviewed.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025

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: 03/21/2025

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Food Service:

· The kitchen was inspected and the food preparation area, and storage areas were observed to be clean and sanitary. A seven (7) day supply of non-perishable food and two (2) day supply of perishable foods were observed in the kitchen.

Health Related Services:

· Clients are assisted with self-administration of prescription and non-prescription medications.

· Five (5) centrally stored client medication records were reviewed. Centrally stored medications are kept in a safe and locked place not accessible to clients in care. Medications are given according to Physician directions.

Incidental Medical and Dental:

· All clients have a Needs and Services Plan.

· Staff training was on file.

Disaster Preparedness, and Emergency Intervention:

· An Emergency Disaster Plan LIC610D is kept in the facility.

· The last documented disaster drill was documented on 9/26/2024.

Emergency Intervention:

· No manual restraints or seclusion are used with clients in care.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during the visit is documented on the LIC809D. Exit interview held and a copy of the report along with appeal rights were provided.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025

LIC809 (FAS) - (06/04)

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