306003747-8-8-2023-28-AS-BPEA-CUHSH2-20230808135249

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003747
Report Date: 08/08/2023
Date Signed: 08/08/2023 01:53:12 PM

Document Has Been Signed on 08/08/2023 01:53 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:	MAPLE HOME		FACILITY NUMBER:	306003747
ADMINISTRATOR:	ROMMEL P. GONZALES		FACILITY TYPE:	735
ADDRESS:	9435 MAPLE STREET		TELEPHONE:	(562) 867-4235
CITY:	BELLFLOWER	STATE: CA	ZIP CODE:	90706
CAPACITY: 4		CENSUS: 4	DATE:	08/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:12 AM
MET WITH:	Rommel Gonzales - Administrator		TIME COMPLETED:	01:58 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 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was screened and met by Kristen Rodriguez/ Direct Service Professional (DSP) and explained the purpose of the visit. Administrator Rommel Gonzales arrived shortly thereafter and assisted LPA with the inspection. The facility is licensed to care for (4) Developmentally Disabled Adults, ages 18 through 59, (4) ambulatory only. All clients residing at this facility receive case management services provided by Harbor Regional Center. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station and PPE supplies located near the front door. The staff is wearing a mask throughout their shift and disposable gloves are used to clean and disinfect the high touched surfaces in the common areas. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Facility has COVID-19 signage posted throughout the facility. Bathrooms have hand washing signs, soap and paper towels. Staff are adhering to infection control requirements. Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan and submitted to CCL. 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 10/12/2023. A fire clearance for (4) clients is in place. Surety Bond (Summa Insurance Services) is in effect and in force with bond amount of $2000. The insurance will expire on 03/07/2024. Last Fire/Diaster Drill was last conducted on 01/01/2023. Physical Plant/Environment Safety: The facility is a single storey home located in a residential neighborhood, contains a total of (5) bedrooms, (4) of which are client bedrooms and (1) is staff bedroom, two (2) full bathrooms, a living room area, kitchen, dining area, backyard, and detached garage. Currently, there are four (4) clients living in the facility. Facility is Level 4G. The interior and exterior physical plant was inspected. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, chair and sufficient closet space. Bathrooms have non-skid materials and contained hygiene supplies including liquid soap, paper towels, and toilet paper. Exit doors are free of any obstruction and there are no pools or large bodies of water. Backyard was inspected and has a shaded area and sitting area. Detached garage was inspected and there is an extra refrigerator/freezer to stock up additional food items. Kitchen knives, sharps objects, cleaning supplies and toxic substances are locked in a cabinet in the home and inaccessible to clients. There is a fire extinguisher observed to be fully charged and was last serviced on 5/19/2023. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Hot water supply measured 106.7 deg F in bathroom #1, and 107.6 in bathroom #2. ***REPORT CONTINUED ON LIC809-C***

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

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: MAPLE HOME	FACILITY NUMBER: 306003747
	VISIT DATE: 08/08/2023

NARRATIVE

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Staffing: A total of four (4) staff members plus 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 two (2) staff. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Administrator certificate is valid and expiring on 03/21/2024. Administrator has a valid HIV/AIDS training proof 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. (1) out of (4) clients have a cell phone and none have an IPad/tablet. LPA attempted to conduct client interviews but (3) were in the Day Program and (1) client is non verbal.
Client Records-Incident Reports: LPA reviewed Client files for C1 through C2. 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.
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 is one (1) client with special diet/diabetic diet 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.
Health Related Services: The medications are centrally stored and in their original containers. Medications were reviewed for C1-C2 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 is one (1) client at this home with diabetes, 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, Rommel Gonzales

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/08/2023 01:53 PM - It Cannot Be Edited

Created By: Bennette Pena On 08/08/2023 at 12:45 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: MAPLE HOME	FACILITY NUMBER: 306003747
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80023(d)(2)

80023 Disaster and Mass Casualty Plan (d) Disaster drills shall be conducted at least every six months. (2) The drills shall be documented and the documentation maintained in the facility for at least one year. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the Administrator did not comply with the section cited above in that last fire and disaster drill was last conducted on 01/01/2023. which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/18/2023
	Plan of Correction
1 2 3 4	Administrator agreed to conduct a fire & disaster drill and will have staff sign and date the training form and submit proof 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

LICENSING EVALUATOR NAME:

Bennette Pena

LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

LIC809 (FAS) - (06/04)

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