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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003751
Report Date: 12/12/2022
Date Signed: 12/12/2022 04:41:10 PM

Document Has Been Signed on 12/12/2022 04:41 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CRJ HOMEFACILITY NUMBER:
306003751
ADMINISTRATOR:CRISTINA SANTOSFACILITY TYPE:
735
ADDRESS:15044 BARNWALL STREETTELEPHONE:
(714) 521-5956
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY: 6CENSUS: 3DATE:
12/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Loida Samonte- Assistant AdministratorTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit to the facility for the purpose of conducting the required annual inspection, using the Infection Control tool to evaluate the facility. LPA Maldonado met with staff Kim Salvador and explained the purpose for the visit. LPA conducted a tour of the physical plant with staff, observed the food supplies, COVID-19 procedures, and reviewed client and staff files, and client's medications. The facility has an approved mitigation plan on file. Assistant Administrator Loida Samonte arrived shortly after to assist with the visit.

The facility is a one-story home located in a residential area. It is licensed to serve (6) developmentally disabled clients, ages 18-59, all ambulatory only. The home consists of a living room, kitchen, dining room, den (3) client bedrooms, (2) staff bedroom, (2) bathrooms, a shaded patio in the backyard with seating, and an attached garage. LPA observed all client bedrooms to have the required furniture, bedding, linens, sufficient lighting, closet space, and additional storage space. (2) bathrooms were observed to have a shower, toilet, and wash basin. During the inspection of the bathrooms, LPA observed 2 cockroaches come out of a bathroom drawer when it was opened and several small dead cockroaches in the drawer. Staff stated they were unaware of any recent issues with cockroaches. The water temperature was tested and measured between 120*F-123*F, which is not in compliance. The food supplies was observed to be the required 2-day perishables and 7-day non-perishables. Fire extinguishers were observed in the kitchen, den, and laundry space in the hallway, to have current inspections and were fully charged. The first aid kit was inspected and was missing required items such as scissors and tweezers. A current first aid manual was observed. All sharps were observed to be locked and inaccessible in a drawer in the kitchen, across from the sink. Cleaning supplies were locked and inaccessible, stored in a cabinet underneath the kitchen sink and in a supply cupboard in the garage. All equipment was operational and in good repair. A hallway closet had additional towels and linens for clients- inspected and in good repair. The smoke/carbon monoxide detectors were tested, were interconnected and operational at the time of the visit. (Report continued on LIC809-C...)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2022
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CRJ HOME
FACILITY NUMBER: 306003751
VISIT DATE: 12/12/2022
NARRATIVE
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LPA observed a 30-day supplies of Personal Protective Equipment (PPE) stored in the garage. PPE siganage was observed throughout the facility to promote hand washing, cough/sneeze etiquette, and social distancing. All hand washing stations are fully stocked with liquid soap and paper towels. LPA was not screened for symptoms of COVID-19 and temperature check was not initiated upon entry, as required by the COVID-19 guidance. Also, LPA and another staff entered through the garage, while a client was observed to enter through the front door- there is not once central entry point designated for universal entry screening.

All client files were reviewed and had updated emergency contact information and health screenings. (3) staff files were reviewed and had Criminal Background Clearances, health screenings, and proof of required annual training and certifications. All client medications were reviewed. LPA discovered that two of client# 1 (C1) medications were not administered as prescribed for 12/12/22 in the morning. Assistant administrator states staff missed to give them to C1.

Per California Code of Regulations, Title 22, and Health and Safety Codes, deficiencies were observed and will be cited on the LIC809-D.

An exit interview was conducted with assistant administrator Loida Samonte and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/12/2022 04:41 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 12/12/2022 at 02:16 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: CRJ HOME
FACILITY NUMBER: 306003751

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2022

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, interview, record review, the licensee did not comply with the section cited above in the water temperature in bathroom# 2 was tested and measured at 123*F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/13/2022
Plan of Correction
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The administrator will adjust the water temperature to be within the required 105*F-120*F by 12/13/22 and will completea water log for the following 7 days. A copy of the water log will be submitted to LPA by 12/20/22.
Type A
Section Cited
CCR
80075(b)(5)(B)
80075 Health Related Services
(b)Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5)If the client's physician has stated... that the client is unable to determine his/her own need for...medication, but can communicate... symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client...: (B) Once ordered by the physician the medication is given according to the physician's directions.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 2 medications for C1 were discovered to not have been administered as prescribed on 12/12/22, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/13/2022
Plan of Correction
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Administrator will ensure that In-Service training is provided to staff who assist in administering medications to clients. A copy of the training material along with a sign in sheet for those who attended will be emailed to LPA by the 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:Fernando Fierros
LICENSING EVALUATOR NAME:Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/12/2022 04:41 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 12/12/2022 at 02:16 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: CRJ HOME
FACILITY NUMBER: 306003751

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)(1)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 2 live cockroaches observed in a bathroom cabinet drawer and a few dead ones, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2022
Plan of Correction
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Administrator has contacted pest control experts and confirmed they will inspect and treat the home this week. A copy of the inspection and work completed will be emailed to LPA by the POC due date.
Type B
Section Cited
CCR
80075(g)
Health-Related Services
(g) If the facility has no medical unit on the grounds, first aid supplies shall be maintained and be readily available in a central location in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in the first aid kit missing required items such as tweezers and scissors, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2022
Plan of Correction
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Administrator will purchase the required items- scissors and tweezers, and provide LPA a picture of the items obtained along with the purchase receipt, via email by the 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:Fernando Fierros
LICENSING EVALUATOR NAME:Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2022


LIC809 (FAS) - (06/04)
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