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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603707
Report Date: 10/17/2024
Date Signed: 10/18/2024 03:35:05 PM

Document Has Been Signed on 10/18/2024 03:35 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:AMALIA HOME - OLYMPICFACILITY NUMBER:
198603707
ADMINISTRATOR/
DIRECTOR:		JOURDAN SANVICTORESFACILITY TYPE:
735
ADDRESS:8526 OLYMPIC BLVD.TELEPHONE:
(562) 805-5615
CITY:PICO RIVERASTATE: CAZIP CODE:
90660
CAPACITY: 4CENSUS: 1DATE:
10/17/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:05 PM
MET WITH:Raymond William Zerde - Direct Support StaffTIME VISIT/
INSPECTION COMPLETED:
02:46 PM
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Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Post-Licensing visit using the full Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Raymond William Zerde, Direct Support Staff (DSP) for the facility, and explained the purpose of the visit. Administrator Jourdan Sanvictores arrived shortly thereafter. There is currently one (1) ambulatory client residing in the facility.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention.

Infection Control:

· Infection control practices and Personal Protective Equipment (PPEs) were observed. LPA observed that the facility has a completed infection control plan.



Physical Plant/Environment Safety:

· The facility is a single-story home located in a residential neighborhood that is licensed for a capacity of four (4) clients between the ages of eighteen (18) through fifty-nine (59), one (1) of which may be non-ambulatory. It consists of four (4) client bedrooms, a kitchen, a dining room, a living room, a laundry room, two (2) client restrooms of which Restroom #1 which had a hot water temperature reading of 106.2 Degrees Fahrenheit, and Restroom #2 had a hot water temperature of 105.4 Degrees Fahrenheit, and also a detached garage Knives along with the chemicals and cleaning supplies are kept locked and inaccessible to clients. A shaded outdoor area was available for clients in the backyard of the facility.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: AMALIA HOME - OLYMPIC
FACILITY NUMBER: 198603707
VISIT DATE: 10/17/2024
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·The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. There are no pools are or bodies of water accessible to the clients. Carbon Monoxide detectors are operational. The facility has one (1) fully charged fire extinguishers that are kept throughout the facility. Cleaning supplies and toxic substances are kept locked and inaccessible to clients.
· Water temperature readings measured between the required 105 - 120 degrees Fahrenheit.

Operational Requirements:

· The Program Design was reviewed.

· Fire clearance was approved by LA County Fire Department for four (4) clients between the ages of 18 – 59, one of which may be non-ambulatory.


· Care and supervision to meet the clients’ needs was observed.

Staffing:

· A total of seven (7) full-time staff members provide care and supervision to the clients.


Personnel Records/Staff Training:

· Administrator’s certificate expires on 12/7/2025.


· Five (5) staff files were reviewed for criminal background clearance and training.
· Personnel records have health/Tuberculosis (TB) screenings, certifications, and 1st Aid/CPR training.

Client Rights/Information:

· Physician orders were reviewed in client files.

Client Records/Incident Reports:

· One (1) client file was reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, nutritional assessments, medication records, and Personal and Incidental (P & I) money were reviewed.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: AMALIA HOME - OLYMPIC
FACILITY NUMBER: 198603707
VISIT DATE: 10/17/2024
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Food Service:

· The kitchen was inspected and the food preparation area, and storage areas were observed to be clean and sanitary. A seven (7) day supply of non-perishable food and two (2) day supply of perishable foods were observed in the kitchen.


· None of the clients of the facility have a restricted health condition or restricted health care plan.

Health Related Services:

· Client is assisted with self-administration of prescription and non-prescription medications.


· One (1) centrally stored client medication records were reviewed. Centrally stored medications are kept in a safe and locked place not accessible to clients in care. Medications are given according to Physician directions.

Incidental Medical and Dental:

· All clients have a Needs and Services Plan on file.

· Staff training was on file.

Disaster Preparedness, and Emergency Intervention:

· An Emergency Disaster Plan LIC610D is kept in the facility.


· The last documented disaster drill was 9/9/2024.

Emergency Intervention:

· No manual restraints or seclusion are used with clients in care.



Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies were observed during the visit. Exit interview held and a copy of the report was provided.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC809 (FAS) - (06/04)
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