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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603609
Report Date: 10/19/2024
Date Signed: 10/19/2024 02:39:48 PM

Document Has Been Signed on 10/19/2024 02:39 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:HALIFAX HOUSEFACILITY NUMBER:
198603609
ADMINISTRATOR/
DIRECTOR:		MAGEE, WANDAFACILITY TYPE:
735
ADDRESS:4539 HALIFAX RD.TELEPHONE:
(626) 443-1313
CITY:EL MONTESTATE: CAZIP CODE:
91731
CAPACITY: 4CENSUS: 4DATE:
10/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:57 AM
MET WITH:DSP Lupe GonzalezTIME VISIT/
INSPECTION COMPLETED:
02:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met DSP worker Lupe Gonzalez at approximately 12:00 PM and explained reason for visit. Administrator Wanda Magee was notified by phone. The facility is licensed to serve 4 ambulatory clients, of which 1 may be non-ambulatory in the age range of 18 through 59. Facility is operating within the scope of its license.

A tour of the single-story facility included the 3 client bedrooms, 2 bathrooms, living room, dining area, kitchen, laundry area, recreation room, front yard, backyard and attached garage.

LPA toured the facility and observed the following: Each client bedroom has the required furniture and bedding. There is extra clean linen and towels in hallway closet. Smoke detectors were observed in each room and throughout the facility and are properly operating. There is 1 carbon monoxide in the dining room and is properly operating. The facility has one (1) fully charged fire extinguishers which is kept in laundry area. Cleaning supplies and toxic substances are inaccessible to clients in a locked storage in garage as well as within other locked cupboards in kitchen. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 45 degrees F. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. There is an extra freezer in garage with more food. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F. The facility does not have a swimming pool or bodies of water on the premises There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction.

SEE LIC 809C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2024
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 10/19/2024 02:39 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 10/19/2024 at 02:17 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: HALIFAX HOUSE
FACILITY NUMBER: 198603609

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above three(3) out of three (3) staff did not have files at facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/02/2024
Plan of Correction
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Administartor will email all documents to LPA.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2024


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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HALIFAX HOUSE
FACILITY NUMBER: 198603609
VISIT DATE: 10/19/2024
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Staff files were not available during today’s visit facility cited. Four (4) client files were reviewed and included physicians report, TB clearance, and individual program plan (IPP)report. Last fire/earthquake drill was conducted in October of 2024. Infectious control plan was reviewed. Four (4) client medications were reviewed. Medications are centrally stored and locked MAR log is used.

Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2024
LIC809 (FAS) - (06/04)
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