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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603724
Report Date: 08/29/2024
Date Signed: 08/29/2024 02:17:48 PM

Document Has Been Signed on 08/29/2024 02:17 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:PHILADELPHIAN HOME IIFACILITY NUMBER:
198603724
ADMINISTRATOR/
DIRECTOR:		RESURRECCION, LEANDROFACILITY TYPE:
735
ADDRESS:10136 WASHINGTON STTELEPHONE:
(562) 732-7514
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 4CENSUS: 1DATE:
08/29/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:55 PM
MET WITH:Andre Degazon - CaregiverTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Licensing Program Analyst (LPAs) Tena Herrera and Daniel Konishi conducted the required Post Licensing inspection. LPAs arrived unannounced and met with Andre Degazon who allowed entrance to the facility, shortly after Administrators Marie and Leandro Resurreccion arrived to assist with the visit the purpose for today’s visit was explained. The facility is licensed to serve (4) ambulatory clients ages 18-59 years, (2) of which may be non-ambulatory (in bedrooms 1 & 2. The facility currently has 1 ambulatory client serviced through Harbor Regional Center.

The facility is a single-story home located in a residential area in Bellflower, Ca. A tour of the facility includes: Kitchen, Dining Area, Living Room, 4 Client bedrooms, 2 Client Bathrooms, Detached Garage (with laundry), front yard and back yard.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:


Infection Control: Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility.
Physical Plant & Environment Safety: LPA toured facility, clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested in the client bathrooms and was within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked cabinet. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged.
(Continued on LIC809-C)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
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: PHILADELPHIAN HOME II
FACILITY NUMBER: 198603724
VISIT DATE: 08/29/2024
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Operational Requirements: Staff have proper training to meet the needs of the clients in care. Facility has an activity area furnished for outdoor use. Last fire/earthquake drill was conducted during todays visit 8/29/24, LPAs informed Administrators that these must be conducted moving forward now that they are admitting clients in the facility.
Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the clients in the case of an emergency.
Personnel Records-Training: Staff files are maintained in a secure location. LPA reviewed 4 staff files during today’s visit, files reviewed contained the following: Criminal Background Clearance, First-Aid/CPR/AED and sufficient on-going training. There is on newly hired staff that did not have (direct support) training's documented in file, Administrator confirmed staff is currently undergoing training's, LPAs advised Administrator that once completed documentation is needed in personnel file, verbal advisory was given. Marie Resurreccion is undergoing a renewal for Administrator Certificate in which LPAs verified in the CCL website.
Client Rights-Information: Facility provides telephone landline and internet for the clients. Client rights posters and reporting posters are displayed within the facility.
Client Records-Incident Reports: Client files are maintained in a secured locked cabinet and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. LPA reviewed 1 client file with no issues.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Service: Staff designated to administer medication have the proper training on file. Medication is properly labeled and are centrally stored in a locked cabinet and are in their original containers. LPAs reviewed 1 clients medication with no issues.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites.
Emergency Intervention: Clients at this facility do not need the use of restraints or de-escalation techniques.
Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during todays visit.
Exit interview was held and a copy of the report was given to Administrators Marie and Leandro Resurreccion.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC809 (FAS) - (06/04)
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