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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004004
Report Date: 08/27/2024
Date Signed: 08/28/2024 08:54:13 AM

Document Has Been Signed on 08/28/2024 08:54 AM - 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:WHITTIER RESIDENTIAL HOMESFACILITY NUMBER:
306004004
ADMINISTRATOR/
DIRECTOR:		GERARDO ZAMORA JR.FACILITY TYPE:
735
ADDRESS:9633 GUNN AVENUETELEPHONE:
(562) 698-1862
CITY:WHITTIERSTATE: CAZIP CODE:
90605
CAPACITY: 6CENSUS: 6DATE:
08/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Gerardo Zamora, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Annual Required Visit on 08/27/2024.. LPA were met by Staff #1 (S1) and explained the purpose of the visit. S1 assisted in tour of facility. Administrator Gerardo Zamora arrived shortly after to the facility and was explained the purpose of the visit. The facility has a fire clearance approved for six (6) ambulatory clients. All clients receive services from East Los Angeles Regional Center. LPAs observed Personnel Report and Resident Roster. The facility currently has 6 clients.
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 and Dental, Disaster Preparedness, and Emergency Intervention.

Infection Control:

· Infection control practices and Personal Protective Equipment (PPEs) were observed.


· LPA observed that the facility does not have an infection control plan in place.

Physical Plant/Environment Safety:

· LPA conducted a tour of the facility with S1 and observed the following:


The facility is a single-story building in a residential area, with a kitchen, dining room, living room, 3 client shared bedrooms, backyard with shaded area and a garage.
· All passageways, walkways, driveway, steps and patio are free from obstructions. The front, back and side areas of the house are free of hazards.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2024
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 7
Document Has Been Signed on 08/28/2024 08:54 AM - It Cannot Be Edited


Created By: Daniel Konishi On 08/27/2024 at 01:32 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: WHITTIER RESIDENTIAL HOMES
FACILITY NUMBER: 306004004

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2024

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, LPA, Daniel Konishi measured client’s restroom #1 water temperature read at 128.3 degrees F and client’s restroom #2 water temperature read at 128.1 degrees F, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2024
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 department 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: 08/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2024


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 08/28/2024 08:54 AM - It Cannot Be Edited


Created By: Daniel Konishi On 08/27/2024 at 01:32 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: WHITTIER RESIDENTIAL HOMES
FACILITY NUMBER: 306004004

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA observed that the facility does not have a Infection Control Plan in place which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/10/2024
Plan of Correction
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Administrator will send current Infection Control Plan to LPA by POC due date.
Type B
Section Cited
CCR
85064(k)
Administrator Qualifications and Duties
(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, Administrator's file is missing training on HIV and TB which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/10/2024
Plan of Correction
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Administrator will send a copy of the HIV and TB training certificate to the 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:David Sicairos
LICENSING EVALUATOR NAME:Daniel Konishi
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2024


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 08/28/2024 08:54 AM - It Cannot Be Edited


Created By: Daniel Konishi On 08/27/2024 at 01:32 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: WHITTIER RESIDENTIAL HOMES
FACILITY NUMBER: 306004004

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA observed that C1 (Client #1) and C2 (Client #2), C3 (Client #3), C4 (Client #4) Physician’s Reports (LIC 602) medical assessment is not on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/10/2024
Plan of Correction
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Administrator will send a copy of C1, C2, C3, and C4 Physician's Report (LIC602) medical assessment to the LPA by the POC due date.
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: 08/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2024


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: WHITTIER RESIDENTIAL HOMES
FACILITY NUMBER: 306004004
VISIT DATE: 08/27/2024
NARRATIVE
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· Hallway linen closet: Contained plenty of linens, towels.

· PPEs and cleaning supplies are stored in a locked cabinet in the garage.

· Beds have the required furniture including bedframes, dressers, lamps, and chairs. Beds have the required linen and the linen is in good condition.

· The facility has one (1) fully charged fire extinguisher located in the kitchen and three (3) fully charged fire extinguishers in the garage.


· Smoke/carbon monoxide detectors are tested and in working condition.
· Cleaning supplies are kept locked in the hallway closet away from food supplies.
· Sharps are kept locked in the hallway closet.
· Shared client bathrooms were observed to be clean and contained soap and paper towels.
· Restroom #1 (R1) had a hot water temperature reading measured at 128.3 Degrees F and Restroom #2 (R2) measured at 128.1 Degrees F which does not fall between the required 105 Degrees F – 120 Degrees F per Title 22 Regulations.

Operational Requirements:
· The facility is licensed for six (6) ambulatory clients.

Staffing:
· A total of six (6) full-time staff members provide care and supervision to the clients.

Personnel Records / Staff Training:

· Administrator’s certificate is effective to 05/22/2026


· LPA observed Administrator HIV & TB training not on file.
· Five (5) staff files were reviewed for criminal background clearance and training.
· Personnel records have health/Tuberculosis (TB) screenings, certifications, and 1st Aid/CPR training.
· Facility has per regulation staff training in file.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
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: WHITTIER RESIDENTIAL HOMES
FACILITY NUMBER: 306004004
VISIT DATE: 08/27/2024
NARRATIVE
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Client Rights/Information:

· Physician orders were reviewed in client files.
· Phone and Internet access is available for the clients use.

Client Records/Incident Reports:

· Six (6) client files were reviewed containing admission agreements, functional capabilities assessment, TB clearance, Individual Program Plan, personal rights, medication records, and Personal and Incidental (P & I) money were reviewed.

· LPA observed that C1 (Client #1) and C2 (Client #2), C3 (Client #3), C4 (Client #4) Physician’s Reports (LIC 602) medical assessment not on file.

Food Services:



· The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.
· No restricted Health Care plan required for the clients in the facility.
Health Related Services:
· Clients are assisted with self-administration of prescription and non-prescription medications.

· Six (6) centrally stored resident medication records were reviewed.


· First Aid Kit was reviewed and has required items.
· LPA observed cabinet located in the kitchen cabinet to be locked and inaccessible to residents. LPA reviewed six (6) out of six (6) client medications and Medication Administration Record (MAR).

Incidental Medical and Dental:

· All clients have a current Individual Program Plan, and COVID-19 vaccination cards on file.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
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: WHITTIER RESIDENTIAL HOMES
FACILITY NUMBER: 306004004
VISIT DATE: 08/27/2024
NARRATIVE
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Disaster Preparedness, and Emergency Intervention:

· A posted Emergency Disaster Plan LIC 610D containing emergency evacuation information was observed.

· An emergency drill was last documented on 06/20/2024.



Emergency Intervention:
· No manual restraints or seclusion are used with clients in care.

Deficiencies were noted on LIC809-D per Title 22 Regulations. Interview was conducted and copy of the report and Appeal Rights were provided to the Administrator.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
LIC809 (FAS) - (06/04)
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