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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603709
Report Date: 01/03/2025
Date Signed: 01/03/2025 02:05:02 PM

Document Has Been Signed on 01/03/2025 02:05 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:JOURNEY TOGETHER MOLINEFACILITY NUMBER:
198603709
ADMINISTRATOR/
DIRECTOR:		ARGUELLES, NELSONFACILITY TYPE:
735
ADDRESS:12239 MOLINE DRIVETELEPHONE:
(562) 325-8418
CITY:WHITTIERSTATE: CAZIP CODE:
90604
CAPACITY: 4CENSUS: 2DATE:
01/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:05 AM
MET WITH:Nelson Arguelles, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Daniel Konishi 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 met with S1 the purpose of the visit was discussed and assisted in the tour of the facility. Administrator, Nelson Arguelles arrived shortly after to assist with the visit.

Facility is licensed to serve four (4) ambulatory only developmentally disabled adults, ages 18-59. There are two ambulatory clients in placement and there are no clients who have a restricted health care condition. All clients residing at this facility receive case management services provided by East Los Angeles Regional Center.



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 Services, Disaster Preparedness, and Emergency Intervention.

During the visit, LPA Konishi observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has sufficient PPE supplies, has an Infection Control Plan in place. Facility has COVID-19 signage posted throughout the facility. Bathrooms have hand washing signs, soap, and paper towels. Facility Administrator is adhering to infection control requirements.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2025
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 4
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: JOURNEY TOGETHER MOLINE
FACILITY NUMBER: 198603709
VISIT DATE: 01/03/2025
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Operational Requirements: Emergency Fire Drill was conducted on 09/15/2024. Emergency Disaster/ Earthquake Drills was conducted on 09/15/2024. Facility Administrator is adhering to operational requirements.

Physical Plant & Environment Safety: The facility is a single-story home located in a residential neighborhood and consists of: Four (4) client bedrooms, 2 bathrooms, living room, kitchen, dining area, garage with laundry washing and drying machine, and a backyard with shaded area.. All client rooms were inspected and LPA observed client beds and the bedding for each bed were in good condition, adequate lighting provided, storage for client personal belongings was observed for each client. Each client bedrooms include all required furniture: a bed, chair, lamps, dressers, and sufficient lighting and closet space. The client’s bathroom is clean, sanitary and in a good working condition. Walls and floors were in good repair. Clean towels, linens, and hygiene products are kept in the hallway closet. Bathroom is clean and operational. Toilets and water faucets worked properly. Showers were free of mold/mildew, had adequate lighting, and there are sufficient toiletries that are accessible to clients. Grab bars observed in the bathroom. Bathroom water temperature was tested as follow: water temperature tested at bathroom #1 at 142.5 degrees F and bathroom #2 at 140.5 degrees F which is not within the required 105-120 degrees F. Facility temperature was comfortable and cool. LPA observed the facility to be clean and appropriately furnished with clear passageways inside and outside. All the sharp knives are locked in the kitchen drawers and inaccessible to clients. Cleaning supplies are locked underneath the kitchen sink and inaccessible to clients. Carbon monoxide detectors were tested and in working condition. Fire extinguishers are in the kitchen and in the garage and both are fully charged.

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

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator, and Staff #1 (S1) to Staff #3 (S3). 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, Employee Rights, Personnel Record on file. Administrator Certificate effective on 03/07/2025. Based on record review, Administrator has the required AIDS/HIV & TB training on file.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025
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: JOURNEY TOGETHER MOLINE
FACILITY NUMBER: 198603709
VISIT DATE: 01/03/2025
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Client Rights-Information: Facility does not have any clients requiring postural supports. Client personal rights and House Rules are posted. Per Facility Administrator, facility provides telephone and wi-fi services to all clients.

Client Records-Incident Reports: LPA reviewed Client files for Client #1 (C1) to Client #2 (C2). Client files are maintained at the facility and have the following documents in their files - Admission Agreements, Face Sheet, Individual Program Plan (IPP), Physician's Report (including T.B and Ambulatory Status), and Clients Personal Rights. LPA reviewed P & I for C1 and C2 with staff.

Food Service: The facility has sufficient food supplies of 2-day perishable and a week of 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. Kitchen is kept clean. LPA observed the Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.

Health Related Services The medications are centrally stored and in their original containers. LPA reviewed medication for C1 through C2. 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. First aid kit was observed and has all required items.

Incidental Medical Services: Based on record review and staff interview, there are no clients under restricted health conditions.

Disaster Preparedness: The facility has an Emergency Disaster Plan readily accessible.

Emergency Intervention: The facility does not use any restraint on clients.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during the visit are documented on the LIC809-D. Exit Interview conducted and a copy of the report with appeal rights were provided to the Administrator, Nelson Arguelles.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/03/2025 02:05 PM - It Cannot Be Edited


Created By: Daniel Konishi On 01/03/2025 at 01:29 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: JOURNEY TOGETHER MOLINE
FACILITY NUMBER: 198603709

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/03/2025

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, LPA, Daniel Konishi measured client’s restroom hot water temperature read at in bedroom #1 at 142.5 degrees F and bathroom #2 at 140.5 degrees F which does not fall between the required 105 to 120 degree F which poses an immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 01/04/2025
Plan of Correction
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Administrator shall immediately adjust water temperature. Administrator to check water temperature at various different times throughout the day and maintain and submit a water temperature log to the LPA for the next 3 days to ensure that hot water temperature falls within 105 degree F and 120 degrees F. Administrator will provide a copy of the log to the LPA once water temperature falls within Title 22 guidelines.
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:Daniel Konishi
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2025


LIC809 (FAS) - (06/04)
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