198603649-3-14-2024-28-AS-BPEA-D3CS9Y-20240314134132

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603649
Report Date: 03/14/2024
Date Signed: 03/14/2024 01:41:59 PM

Document Has Been Signed on 03/14/2024 01:41 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:	EVOLVE CARE, INC		FACILITY NUMBER:	198603649
ADMINISTRATOR:	DE VERA, MATTHEW		FACILITY TYPE:	735
ADDRESS:	1708 LINCOLN AVENUE		TELEPHONE:	(818) 749-2745
CITY:	PASADENA	STATE: CA	ZIP CODE:	91103
CAPACITY:	4	CENSUS: 3	DATE:	03/14/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:42 AM
MET WITH:	Matthew De Vera - Administrator Jeaneth Cabrera - DSP I & II		TIME COMPLETED:	01:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required 1-yr visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Jeaneth Cabreral, Direct Care Staff I & II (DSP I & II) and explained the purpose of the visit. At 11:00am, Matthew De Vera, Administrator arrived and assisted LPA with the inspection. The facility is licensed to care for (4) Developmentally Disabled Adults, ages 18 through 59, ambulatory only. All clients residing at this facility receive case management services provided by Frank D. Lanterman Regional Center. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Facility has not developed, completed and submitted the Infection Control Plan as required by CCL. Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located at the entrance on the the side front door. Staff stated that disposable gloves are used to clean and disinfect the high touched surfaces in the common areas. Staff also stated they use gloves when handling food and assisting with medication. Staff are adhering to infection control requirements. Physical Plant/Environment Safety: The facility is a single storey home located in a residential neighborhood, contains four (4) client bedrooms, three (3) full bathrooms, a living room, kitchen, dining area, and a backyard. Facility does not have a garage. Currently, there are three (3) clients living in the facility. Facility is Level 4I. The interior and exterior physical plant was inspected. Client bedrooms were toured. Each bedroom has a smoke detector/carbon monoxide, bed, linen, dresser, night stand, light, chair and sufficient closet space. Bathrooms have non-skid materials and contained hygiene supplies including liquid soap and toilet paper. Exit doors are free of any obstruction. Backyard was inspected and there were no debris or any obstructions. LPA observed a stand alone small house in the backyard to be used as an office. Kitchen knives, sharps objects, cleaning supplies and toxic substances are locked and inaccessible to clients. There are two (2) fire extinguishers observed to be fully charged and mounted on the wall in the kitchen area and next to the laundry area. Smoke alarms and carbon monoxide are interconnected and approved in the fire clearance, and were tested and operable. There are no firearms or weapons stored at the facility. There is no swimming pool or body of water observed. Water temperature readings did not measure within the required 105 - 120 degrees Fahrenheit. At 10:20am, LPA checked the hot water supply and measured at 128.6 deg F in bathroom #1, 125.7 deg F in bathroom #2 and 127.5 deg F in bathroom #3. Operational Requirements: A current Plan of Operation was reviewed. A fire clearance for four (4) ambulatory clients is in place. Liability Insurance policy in the amount of $1,000,000.00 each occurrence and $3,000,000.00 in the total annual aggregate is valid and will expire on 05/17/2024. Surety Bond is in effect and in force with bond amount of $2000. Administrator stated that the fire drill was last conducted with staff in July 2023, but there is no record on file. **REPORT CONTINUED ON LIC809-C***

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024

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: EVOLVE CARE, INC	FACILITY NUMBER: 198603649
	VISIT DATE: 03/14/2024

NARRATIVE

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Staffing: A total of thirteen (13) 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.
Personnel Records/Staff Training: Reviewed files for three (3) staff. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Administrator certificate is valid and will expire on 07/04/2024. Administrator has the proof of HIV training 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. DSP Cabrera stated that no clients have their own personal cell phone and (1) out of (3) clients have their own tablet. LPA was not able to interview the clients. One (1) client present during the visit is non verbal and the other two (2) clients are out in the Day Program.
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 (clean and well maintained). There are no clients with special diets residing at this facility. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.
Client Records-Incident Reports: LPA reviewed Client files for C1 through C4. 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 C1-C3 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: Per the Administrator, there are no clients at this home with incidental medical services nor have a restricted health condition.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan. Emergency Intervention: Not-Applicable.

Deficiencies cited on LIC 809D. Exit interview, appeals rights and a copy of this report was provided to the Administrator, Matthew De Vera.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/14/2024 01:41 PM - It Cannot Be Edited

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: EVOLVE CARE, INC	FACILITY NUMBER: 198603649
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/14/2024

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that LPA checked the hot water temperature and readings did not measure within the required 105 - 120 degrees Fahrenheit. At 10:20am, hot water supply measured at 128.6 deg F in bathroom #1, 125.7 deg F in bathroom #2 and 127.5 deg F in bathroom #3 which poses an immediate health, safety or personal rights risk to clients in care.
	POC Due Date: 03/15/2024
	Plan of Correction
1 2 3 4	Administrator agreed to send a 7-day log of the hot water temperature measured in the am & pm. Administrator to submit the completed log to CCL/LPA by 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	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/14/2024 01:41 PM - It Cannot Be Edited

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: EVOLVE CARE, INC	FACILITY NUMBER: 198603649
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85095.5(c)

Infection Control Requirements

(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, record review, the licensee did not comply with the section cited above in that the Administrator has not developed, completed and submitted the required Infection Control Plan (LIC9282) which poses/posed a potential health, safety or personal rights risk to clients in care.
	POC Due Date: 03/20/2024
	Plan of Correction
1 2 3 4	Administrator agreed to develop, complete LIC9282/Infection Control Plan as required by CCL and submit to LPA/CCL by POC due date.

Type B

Section Cited

CCR

80077.3(a)

Care for Clients who Lack Hazard Awareness or Impluse Control

(a) If a client requires protective supervision because of running/wandering away, supervision may be enhanced by fencing yards, using self-closing latches and gates, and installing operational bells, buzzers, or other auditory devices on exterior doors to alert staff when the door is opened. The fencing and devices must not substitute for appropriate staffing. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, the licensee did not comply with the section cited above in that the sliding door in bedroom #4 did not have an auditory device which poses/posed a potential health, safety or personal rights risk to clients in care.
	POC Due Date: 03/20/2024
	Plan of Correction
1 2 3 4	Administrator will purchase and install the auditory device on the sliding door in bedroom #4 and submit photos 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	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 03/14/2024 01:41 PM - It Cannot Be Edited

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: EVOLVE CARE, INC	FACILITY NUMBER: 198603649
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1565(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, record review, the licensee did not comply with the section cited above in that Administrator has not conducted the fire drill training with staff since July 2023 and there is no record of training on file which poses/posed a potential health, safety or personal rights risk to clients in care.
	POC Due Date: 03/20/2024
	Plan of Correction
1 2 3 4	Administrator will conduct the fire & earthquake drill with the staff for each shift and send copy of the in-service training, signed & dated to CCL/LPA by 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	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024

LIC809 (FAS) - (06/04)

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