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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603584
Report Date: 03/22/2024
Date Signed: 03/22/2024 01:34:35 PM

Document Has Been Signed on 03/22/2024 01:34 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:LOS ROBLES GUEST HOMEFACILITY NUMBER:
198603584
ADMINISTRATOR:AVILA, LEAHFACILITY TYPE:
735
ADDRESS:1657 N LOS ROBLESTELEPHONE:
(626) 797-0808
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 12CENSUS: 5DATE:
03/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:12 AM
MET WITH:Leah, Avila, Administrator and Lily McColganTIME COMPLETED:
01:39 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced visit at the facility for the purpose of conducting the required annual inspection. LPA utilized the Compliance and Regulatory Enforcement (CARE) Tool to evaluate the facility. LPA Lopez met with Leah Avila, Administrator and Lily McColgan LPA explained the purpose of the visit.

The facility is licensed to serve 12 ambulatory and developmentally disabled clients aged 18 to 59. Currently, there are five (5) clients in placement. One client is over 60 years of age. 4 Clients are provided Case Management services by Frank D Lanterman Regional center.

Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves.
while assisting clients. Staff are disinfecting often for high touched surfaces. Facility has sufficient PPE supplies, has an Infection Control Plan and Mitigation Plan. Bathrooms have hand washing signs, soap and paper towels. Per Facility Administrator all staff also have the COVID-19 vaccines including boosters. Facility Administrator is adhering to infection control requirements.

Operational Requirements: Fire Drills are conducted every three months; the last fire drill was conducted on 01/07/2024 Emergency Disaster/ Earthquake Drills are conducted every three months and the last one was conducted on 01/072024.

LIC 809C for continuation of report.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 03/22/2024 01:34 PM - It Cannot Be Edited


Created By: Alberto Lopez On 03/22/2024 at 12:35 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: LOS ROBLES GUEST HOME
FACILITY NUMBER: 198603584

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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. LPA measured the water temperature at facility at 120.3 - 122.7 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/23/2024
Plan of Correction
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Administrator will adjust water temperature and keep log for 7 days and send proof to LPA by POC 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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/22/2024 01:34 PM - It Cannot Be Edited


Created By: Alberto Lopez On 03/22/2024 at 12:35 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: LOS ROBLES GUEST HOME
FACILITY NUMBER: 198603584

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2024

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. The cleaning solutions were unlocked when LPA arrived at facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
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Staff locked up the cleaning solutions during visit.***NO FURTHER ACTION REQUIRED***
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

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. One screen was torn on the side of home which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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Administrator will repair or replace torn screen outside and send proof to LPA by POC 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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024


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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: LOS ROBLES GUEST HOME
FACILITY NUMBER: 198603584
VISIT DATE: 03/22/2024
NARRATIVE
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Physical Plant & Environment Safety:

The facility is a two- story home located on a residential street. The facility consists of living room, one staff office, client office, kitchen, dining room, 8 client bedrooms, 4 client bathrooms, detached garage, and enclosed backyard. and indoor/outdoor activity areas. LPA observed appropriate furniture, lighting fixtures, personal storage space as required, Beds have adequate amount of linen and mattresses, and box springs are in good repair. Bathrooms were found to be within Title 22 regulations. Toilets and water faucets worked properly. Bathroom sinks and showers were free of mold/mildew. LPA observed that sufficient toiletries accessible to clients. Water temperature measured between 120.3 -122.7 degrees F which is not within range of 105.0 – 120 Degrees F.. LPA observed the facility to be clean and appropriately furnished with clear passageways inside and outside. First aid kit is fully stocked with manual, smoke alarms and carbon monoxide detectors were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to clients. Hazardous toxins and/or items are accessible to clients under the kitchen sink which was unlocked. Facility staff promptly locked them up. Fire extinguisher(s) are fully charged. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. Exits were marked with signs. Notifications and postings were observed which included personal rights, visitor policy, complaint procedures, menu, and emergency disaster plan. One screens outside had tears and in need of repair or replacement,




Staffing: There is sufficient staffing at the facility. Staff employed are over the age of 18, are fingerprint and cleared and associated to the facility.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator, and S1-S7. Staff have current CPR/first aid training and sufficient on-going training that meets the annual requirement. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting. Administrator Certificate expired 10/21/2023. Renewal has been submitted on 10/16/2023 and is pending.

Client Rights-Information: Client personal rights and House Rules are posted. Per Facility Administrator, facility provides wi-fi services for facility clients.


SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
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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: LOS ROBLES GUEST HOME
FACILITY NUMBER: 198603584
VISIT DATE: 03/22/2024
NARRATIVE
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Client Records-Incident Reports: LPA reviewed Client files for C1 through C5. Client files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Appraisal Needs and Services Plan, Functional Capabilities Assessment, Mental Health Intake Assessment, Client Cash Resources. Special Incident Reports, Client Personal Property and Clients Personal Rights but client C1, C2, C3 need updated IPPs and C4 needs updated Physician’s report for the elderly (LIC602)

Food Service: The facility has sufficient food supplies of 2-day perishable and 7 day supply of non-perishable items. The food is properly stored in the refrigerator which is clean and well-maintained. There are no clients with special diets residing at this facility. Kitchen is kept clean and free from rodents and other bugs/ insects. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services: The medications are centrally stored and in their original containers. LPA reviewed medication for C1-C5. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubble packed and delivered monthly.

Incidental Medical Services: Per Facility Administrator, there are no clients at this home with incidental medical services or restricted health condition.

Disaster Preparedness: The facility has an Emergency Disaster Plan but needs to be updated.

Emergency Intervention: Not Applicable.

Deficiencies noted. Technique advisories provided. Exit interview and a copy of this report, 809D and appeal rights was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 03/22/2024 01:34 PM - It Cannot Be Edited


Created By: Alberto Lopez On 03/22/2024 at 01:19 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: LOS ROBLES GUEST HOME
FACILITY NUMBER: 198603584

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80068.2(b)(1)(2)
80068.2(b)(1)(2). Needs and Services Plan.


(b) If the client has an existing needs appraisal or individual program plan (IPP) completed by a placement agency, or a consultant for the placement agency, the Department may consider the plan to meet the requirements of this section provided that:

(1) The needs appraisal or IPP is not more than one year old.

(2) The licensee and the placement agency agree that the client's physical, mental and emotional status has not significantly changed since the assessment.

This requirement is not met as evidenced by:
C1, C2, C3 need to have IPPs updated.
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above. C1, C2, C3 have IPPs done in 2020 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/05/2024
Plan of Correction
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Administrator will update IPPs for C1, C2, C3 and send proof to LPA by POC 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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024


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