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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003757
Report Date: 10/28/2024
Date Signed: 10/28/2024 02:09:28 PM

Document Has Been Signed on 10/28/2024 02:09 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:MILLS CARE HOMEFACILITY NUMBER:
306003757
ADMINISTRATOR/
DIRECTOR:		RAFAEL TORRESFACILITY TYPE:
735
ADDRESS:9737 MILLS AVENUETELEPHONE:
(562) 945-6416
CITY:WHITTIERSTATE: CAZIP CODE:
90604
CAPACITY: 4CENSUS: 4DATE:
10/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:21 PM
MET WITH:Edwin Teoco DSPTIME VISIT/
INSPECTION COMPLETED:
02:25 PM
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Regulatory Enforcement (CARE) tools. LPA met DSP worker Edwin Teoco at approximately 12:20 PM and explained reason for visit. Administrator Jacky Mikin was notified by phone.

Facility is licensed to serve Four (4) developmentally disabled adults, ages 18-59. Facility is vendorized by Eastern Los Angeles Regional Center. The facility is in a residential area, and it is a one story family home. A tour of the single-story facility included the living room, kitchen, 3 client bedrooms, staff room, 2 client bathrooms, staff bathroom, laundry area, front yard, backyard, and detached garage.

LPA toured the facility and observed the following: Each client bedroom has the required furniture and bedding. There is extra clean linen and towels in each clients closet. Smoke detectors/carbon monoxide detectors were observed in each room and throughout the facility and are properly operating. The facility has one (1) fully charged fire extinguishers which is kept in kitchen. Cleaning supplies and toxic substances are inaccessible to clients in a locked cupboards in kitchen. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 45 degrees F. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. There is an extra freezer in garage with more food. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were not measured between the required range of 105-120 degrees F. Bathroom #2 measured at 130 degrees deficiency cited. The facility does not have a swimming pool or bodies of water on the premises There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction.

SEE LIC 809C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
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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Document Has Been Signed on 10/28/2024 02:09 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 10/28/2024 at 01:58 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: MILLS CARE HOME
FACILITY NUMBER: 306003757

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2024

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 [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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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:Tony Vasallo
LICENSING EVALUATOR NAME:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


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: MILLS CARE HOME
FACILITY NUMBER: 306003757
VISIT DATE: 10/28/2024
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Three (3) staff files were reviewed and included Criminal clearance record, CPR/training, and health screening with TB. Four (4) client files were reviewed and included physicians report, TB clearance, and individual program plan (IPP) report. Last fire/earthquake drill was conducted in July of 2024. Infectious control plan will be mailed to LPA. Zero (0) clients were interviewed three were at day program and one client is nonverbal one (1) staff was interviewed. Four (4) client medications were reviewed. Medications are centrally stored and locked MAR log is used.

Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
LIC809 (FAS) - (06/04)
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