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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603558
Report Date: 06/03/2023
Date Signed: 06/03/2023 01:52:26 PM

Document Has Been Signed on 06/03/2023 01:52 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:CHARM HOUSE IIFACILITY NUMBER:
198603558
ADMINISTRATOR:CLARKE, CHRISTALFACILITY TYPE:
735
ADDRESS:9570 MAYNE STREETTELEPHONE:
(323) 403-8268
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 4CENSUS: 0DATE:
06/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:27 AM
MET WITH:Errol Jordan WilliamsTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was screened and met by Arleen Santos/ Direct Service Professional (DSP) and explained the purpose of the visit. Administrator Christal Clarke and Licensee Jeremy Miller will not be able to come to the facility. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station and PPE supplies located near the front door. There is no staff present at the facility. The Licensee will submit the COVID-19 Mitigation Plan and Infection Control Plan to CCL. Facility has COVID-19 signage posted by the entrance.

Physical Plant/Environment Safety: The facility is a 2 storey home located in a corner lot of a residential neighborhood, contains a total of (3) bedrooms, (3) full bathrooms, a living room/activity area, kitchen, dining area, attached garage and front/side yard.The facility is licensed to care for (4) Developmentally Disabled Adults, ages 18 through 59, ambulatory only. There are no clients living in the facility at the moment. All future clients to reside at this facility will receive case management services provided by Harbor Regional Center. The interior and exterior physical plant was inspected. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, chair, nigh stand and sufficient closet space. Bathroom in the Master's bedroom did not have supplies like toilet paper, soap and paper towel. (1) of the bathrooms has non-skid materials but did not contain hygiene supplies including liquid soap, paper towel, and toilet paper in one of the bathrooms. There is a phone at the facility but call could go through, out of service. There is a phone at the facility but call could not go through, it was out of service. xit doors are free of any obstruction and there are no pools or large bodies of water. Front and side yards were inspected, and the front yard has a shaded area, sitting area and designated one corner for smoking. Attached garage was inspected and LPA observed chemicals such as paints, pain thinners, disinfectants, cleaning supplies on the floor and not kept in a safe secure, locked location. There is an extra refrigerator/freezer to stock up additional food items next to the laundry area. Kitchen knives, sharps objects, cleaning supplies and toxic substances are locked and inaccessible to clients. There are (2) fire extinguishers observed, one in the kitchen and one in the upstairs hallway, but there was no indication when they were purchased or when they were serviced. Licensee purchased a new fire extinguisher and provided LPA the receipt and photo of the fire extinguisher by text messaging. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. Water temperature readings measured within the required 105 - 120 deg F. Hot water supply measured 111.8 deg F in the kitchen, 110.8 deg F in bathroom #1, 112.6 deg F in bathroom #2 and 113.1 deg F in bathroom #3.

Operational Requirements: A current Plan of Operation was unavailable and LPA was not able to review. Licensee stated that he will submit the Infection Control Plan to LPA/CCL. A fire clearance for (4) clients is in place and was granted on 4/01/2022.

*****REPORT CONTINUED ON LIC809-C*****.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 06/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/03/2023
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: CHARM HOUSE II
FACILITY NUMBER: 198603558
VISIT DATE: 06/03/2023
NARRATIVE
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Staffing: There are (2) staff associated to the facility, Licensee and Administrator. One (1) individual at the facility during the visit is over the age of 18 but did not have criminal background clearance, fingerprint cleared, have training and associated to the facility.

Personnel Records/Staff Training: No staff files were reviewed during the visit. The files are in a locked cabinet and the individual in the facility does not have an access to it. Administrator certificate is not valid and expired on 10/01/2022. Licensee submitted the renewed/valid Administrator certificate during the visit, it is expiring 10/01/2024.

Client Rights-Information: Client personal rights are posted.

Client Records-Incident Reports: No client files were reviewed during the visit. Currently, there are no clients at this home.

Food Service: There are sufficient food supplies of 2-day perishable and 7-day non-perishable items. The food is properly stored in the refrigerator. There are no clients at this facility during the visit. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services: No medications were reviewed at this time. The medications will be centrally stored in a locked cabinet in the office which will be inaccessible to clients. Currently, there are no clients at this home.

Incidental Medical Services: Currently, there are no clients at this home.

Disaster Preparedness: Licensee will send a copy of the complete Emergency Disaster and Mass Casualty Plan to CCL.

Emergency Intervention: Not-Applicable.

Deficiencies cited on LIC 809D. Exit interview, appeals rights and a copy of this report was provided to the Errol Jordan Williams.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 06/03/2023 01:52 PM - It Cannot Be Edited


Created By: Bennette Pena On 06/03/2023 at 01:03 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: CHARM HOUSE II
FACILITY NUMBER: 198603558

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 in that LPA observed chemicals such as paints, pain thinners, disinfectants, cleaning supplies on the floor in the garage which were not kept in a safe secure, locked location which poses a potential health, safety or personal rights risk to clients in care.
POC Due Date: 06/09/2023
Plan of Correction
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Licensee will submit photos to CCL/LPA showing that the chemicals, toxic substances and other hazardous materials are stored in a locked and secured location by POC due date.
Type B
Section Cited
CCR
80073(a)
Telephones
(a) All facilities shall have telephone service on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the licensee did not comply with the section cited above in which there is a phone at the facility but call could not go through when tested by LPA, it was out of service which poses a potential health, safety or personal rights risk to clients in care.
POC Due Date: 06/09/2023
Plan of Correction
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Licensee will ensure that a telephone service is working in the facility and will submit proof that the phone is back in service 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: 06/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2023


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 06/03/2023 01:52 PM - It Cannot Be Edited


Created By: Bennette Pena On 06/03/2023 at 01:03 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: CHARM HOUSE II
FACILITY NUMBER: 198603558

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80019(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in that the individual present and staying in the facility is not associated to the facility and did not have the required record clearance and background check which poses a potential health, safety or personal rights risk to clients in care.
POC Due Date: 06/14/2023
Plan of Correction
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Licensee will ensure that individuals and staff must have a criminal background check and record clearance prior to working or staying in the facility. Licensee will submit the criminal background clearance, fingerprint clearance of the individual and associate him to the facility via Guardian to CCL/PA by POC due date.
Type B
Section Cited
CCR
80066(a)(12)(B)1
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) For employees that are required to be fingerprinted pursuant to Section 80019: (B) Documentation of either a criminal record clearance or exemption as required by Section 80019(e). 1. For Certified Administrators, a copy of their current and valid Administrator Certification meets this requirement.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in which the Administrator's certificate posted on the wall is not valid and expired on 10/01/2022 which poses a potential health, safety or personal rights risk to clients in care.
POC Due Date: 06/03/2023
Plan of Correction
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Licensee submitted a renewed/valid certificate during the visit, expires on 10/01/2024. The deficiency has been cleared during the visit.
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: 06/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2023


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 06/03/2023 01:52 PM - It Cannot Be Edited


Created By: Bennette Pena On 06/03/2023 at 01:03 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: CHARM HOUSE II
FACILITY NUMBER: 198603558

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(e)
Personnel Records
(e) All personnel records shall be maintained at the facility site.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the licensee did not comply with the section cited above in which there are no personnel records that can be reviewed in the facility. Some facility files are in a locked cabinet and the individual present in the facility does not have an access to it which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 06/09/2023
Plan of Correction
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Licensee will ensure that personnel records and facility files are accessible to licensing agency upon inspection. Licensee will send a plan to CCL/LPA indicating how staff will be able to access records and files upon licensing requests to view the records 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: 06/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2023


LIC809 (FAS) - (06/04)
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