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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603531
Report Date: 07/30/2024
Date Signed: 07/30/2024 04:47:36 PM

Document Has Been Signed on 07/30/2024 04:47 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:FAIR OAKS MANORFACILITY NUMBER:
198603531
ADMINISTRATOR/
DIRECTOR:		ALMERO, CARMENFACILITY TYPE:
735
ADDRESS:1753 N. FAIR OAKS AVE.TELEPHONE:
(626) 345-9788
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 14CENSUS: 12DATE:
07/30/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:32 PM
MET WITH:Marycel Campos - AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Case Management Annual Continuation visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Maria Liliosa Franco, Direct Care Staff and Tessie Bato, Direct Care Staff and explained the purpose of the visit. At 2:20pm, Administrator Marycel Campos arrived and assisted LPA with the visit. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Physical Plant/Environment Safety: The facility is located in a residential neighborhood and the home has 2 floors, ground floor and the main floor. Main floor is the only area that is licensed which contains a total of (7) client bedrooms, (1) staff bedroom, (4) bathrooms, a living room, office area, kitchen, dining area, front patio and backyard with shaded area. There is a storage room in the ground floor where additional supplies are stored. The garage in the ground floor was converted into an additional live in unit by staff and is inaccessible to clients. The ground floor has separate entrances/exits. Currently, there are twelve (12) clients living in the facility. The interior and exterior physical plant was inspected. Client rooms were toured and have the required furnishings. Exit doors are free of any obstruction and there are no pools or large bodies of water. Backyard has a shaded area and sitting area. Laundry area is in the ground floor which is kept locked when not in use. There are (5) fire extinguishers all over the home which was just serviced on 07/24/2024. There is a fire alarm pull station in the hallway and the home is equipped with a centralized sprinkler system. The home has a central heating system and individual AC units inside each client bedroom. The home was inspected by the Pasadena Fire Dept. on 4/12/2024 and did not pass due to lack of fire alarm protective piece in the electrical panel next to the dining room. Re-inspection by the Fire Dept. was scheduled after 5/10/2024. There are no cameras, firearms or weapons stored at the facility. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Readings were 109.5 deg F in bathroom #1, 108.3 deg. F in bathroom #2 and 110.5 deg F in bathroom #3.
Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. A fire clearance is in place. Surety Bond in the amount of $10000 is valid and expires on 7/19/2027. Last fire drill was conducted on 10/15/2023 and earthquake drill was conducted on 8/25/2023.
Staffing: A total of none (9) staff members including the Administrator provide care and supervision to the clients. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility.
*****CONTINUED ON LIC809-C*****
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/30/2024
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: FAIR OAKS MANOR
FACILITY NUMBER: 198603531
VISIT DATE: 07/30/2024
NARRATIVE
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Personnel Records/Staff Training: Reviewed files for three (3) staff. Proof of staff training, health clearance and vaccinations are current. However, first aid/CPR training for Staff #1 expired on 4/05/2024. Administrator certificate is valid and expires on 12/23/2024. Administrator did not have a valid HIV/AIDS training proof at the time of visit.
Client Rights-Information: Client personal rights are posted. Per Administrator, facility provides internet services to all clients and have access to the facility phone. Administrator stated that (2) clients have personal cell phones and none of the clients have their own tablet/IPad. LPA interviewed (5) clients.
Client Records-Incident Reports: LPA reviewed (3) client files. Client files are maintained at the facility. Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Individual Program Plan (IPP), Behavioral Reports, Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights observed.
Health Related Services: The medications are centrally stored and in their original containers. Medications were reviewed for (5) clients to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubbled packed.
Incidental Medical Services: None of the clients at this home has a restricted health condition.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan.
Emergency Intervention: Not-Applicable.


Deficiencies cited and technical violation issued. Exit interview, appeals rights and a copy of this report was provided to the Administrator, Marycel Campos.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 07/30/2024 04:47 PM - It Cannot Be Edited


Created By: Bennette Pena On 07/30/2024 at 04:11 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: FAIR OAKS MANOR
FACILITY NUMBER: 198603531

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80020(c)
Fire Clearance
(c) A licensee of an Adult Residential Facility or Group Home utilizing secured perimeters shall conduct fire and earthquake drills pursuant to Health and Safety Code section 1531.15(h).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, record review, the Administrator did not comply with the section cited above in that no current fire and earthquake drills were conducted with staff. Earthquake drill was last conducted on 8/25/2023 and Fire drill was conducted on 10/15/2023 which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 08/13/2024
Plan of Correction
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Administrator will ensure that fire and earthquake drills are conducted at least once every six months on each shift and shall include, at a minimum, all direct care staff. Administrator will conduct fire & earthquake drills, document it and include all staff named during each shift. Submit a copy of the fire and earthquake drill logs to CCL/LPA by POC due date.
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 interview, record review, the Administrator did not comply with the section cited above in that the Administrator did not have proof of HIV/Aids training which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 08/13/2024
Plan of Correction
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Administrator agreed to send a copy of the HIV/Aids certificate to CCL/LPA by POC due date.
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:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/30/2024 04:47 PM - It Cannot Be Edited


Created By: Bennette Pena On 07/30/2024 at 04:23 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: FAIR OAKS MANOR
FACILITY NUMBER: 198603531

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
80075 Health Related Services (f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.



This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, record review, the Administrator did not comply with the section cited above in that Staff #1 did not have a valid First aid/CPR training, it expired on 4/05/2024 which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 08/13/2024
Plan of Correction
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Administrator will send a copy of the valid/current first aid/CPR training for Staff #1 to CCL/LPA by POC due date.
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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024


LIC809 (FAS) - (06/04)
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