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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004234
Report Date: 12/11/2023
Date Signed: 12/11/2023 03:05:28 PM

Document Has Been Signed on 12/11/2023 03:05 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:HUBER AVENUE HOME, THEFACILITY NUMBER:
306004234
ADMINISTRATOR:JOSE R. DE LA CRUZFACILITY TYPE:
735
ADDRESS:15500 BLAINE AVENUETELEPHONE:
(562) 489-4085
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 4CENSUS: 4DATE:
12/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Joy De La Cruz - AdministratorTIME COMPLETED:
03:00 PM
NARRATIVE
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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 met by Florinda Aleman, Direct Support Professional (DSP) and explained the purpose of the visit. Shortly thereafter, another staff, Mercedes Bedolla, Direct Support Professional (DSP) arrived. One of the Administrators, Joy De La Cruz arrived at 11:30am and LPA discussed the purpose of the visit and was assisted. The facility is licensed to care for (4) Developmentally Disabled Adults, (2) ambulatory and (2) non-ambulatory with restricted health conditions, ages 18 through 59. 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: The facility does not have an Infection Control Plan in place. Infection control practices and Personal Protective Equipment (PPEs) were maintained, however. The staff stated that they use disposable gloves to clean and disinfect the high touched surfaces in the common areas. The facility has submitted a COVID-19 Mitigation Plan. Bathrooms have hand washing signs, soap and paper towels. Staff are adhering to infection control requirements.
Physical Plant/Environment Safety: The facility is a single storey home located in a residential neighborhood, contains a total of (4) client bedrooms, (2) bathrooms, a living room, kitchen, dining area, backyard and attached garage. Currently, there are four (4) clients living in the facility. 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, and toilet paper. LPA observed a broken faucet without the handle in bathroom #2 and approx. 6 inch hole in bathroom #1's wall. Exit doors are free of any obstruction and there are no pools or large bodies of water. LPA also observed old/broken chairs, broken window/door screens and unused paints in the side yard. Backyard was inspected and has a shaded area and sitting area. Attached garage was inspected. Kitchen was inspected and knives, sharps objects, cleaning supplies and toxic substances are locked under the kitchen sink cabinet and inaccessible to clients. However, LPA observed the laundry and other cleaning supplies which are stored in the upper cabinet in the laundry area was unlocked and accessible to clients. There is (1) fire extinguisher observed to be fully charged and last serviced on April 4, 2023. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. Water temperature readings measured at 105.4 deg F in bathroom #1 and 105.9 deg F in bathroom #2 which are within the required 105 - 120 degrees Fahrenheit.
Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has not been added to the Plan. A fire clearance is in place. 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 09/22/2024. Surety Bond is in effect and in force. The insurance will expire on 04/15/2026. Last Fire Drill was last conducted on 08/20/2023 and is not being conducted on a quarterly basis.

*****REPORT CONTINUED ON LIC809-C*****
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2023
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: HUBER AVENUE HOME, THE
FACILITY NUMBER: 306004234
VISIT DATE: 12/11/2023
NARRATIVE
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Staffing: A total of eight (8) staff members including the (2) Administrators 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 three (3) staff. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Administrator, Joy De La Cruz certificate is valid and expiring on 02/10/2025. 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. Administrator stated two (2) of the clients have a personal cell phone and (3) out of (4) clients have their own tablet. LPA conducted (2) client interviews, as the other (2) are out in the community.
Client Records-Incident Reports: LPA reviewed Client files for C1 through C4. 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). 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-C4 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, no client at this home has a restricted health condition. Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan.
Emergency Intervention: Not-Applicable.

Deficiencies cited and Technical Assistance were issued. Exit interview, appeals rights and a copy of this report was provided to the Administrator, Joy De La Cruz.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 12/11/2023 03:05 PM - It Cannot Be Edited


Created By: Bennette Pena On 12/11/2023 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: HUBER AVENUE HOME, THE
FACILITY NUMBER: 306004234

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2023

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 interview and record review, the Administrator did not comply with the section cited above in that the Administrator/Licensee has not developed and submitted the Infection Control Plan as required by CCL which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 12/20/2023
Plan of Correction
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Administrator will create and develop the Infection Control Plan as required and will submit to CCL/LPA by POC due date.
Type B
Section Cited
CCR
80087(b)
Building and Grounds
(b) All clients shall be protected against hazards within the facility through provision of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the Administrator did not comply with the section cited above in that the laundry and other cleaning supplies which are stored in the upper cabinet in the laundry area was unlocked and accessible to clients which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 12/15/2023
Plan of Correction
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Administrator will ensure that laundry and cleaning supplies are always locked and inaccessible to clients. Administrator will put a lock on the laundry door and submit photos to CCL/LPA by 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:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2023


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 12/11/2023 03:05 PM - It Cannot Be Edited


Created By: Bennette Pena On 12/11/2023 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: HUBER AVENUE HOME, THE
FACILITY NUMBER: 306004234

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the Administrator did not comply with the section cited above in that LPA observed old/broken chairs, broken window/door screens and unused cans of paints in the side yard which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 12/22/2023
Plan of Correction
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Administrator will ensure that the side yard and back yard are free of obstruction, Administrator will clear out the side yard and submit photos to CCL/LPA by POC due date.
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the Administrator did not comply with the section cited above in that LPA observed a broken faucet without the handle in bathroom #2 and approx. 6 inch hole in bathroom #1's wall which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 12/22/2023
Plan of Correction
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Administrator will fix the broken faucet in bathroom #2 and the hole on the wall in bathroom #1. Administrator will submit proof such as photos/service report/invoice to CCL/LPA by 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:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2023


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 12/11/2023 03:05 PM - It Cannot Be Edited


Created By: Bennette Pena On 12/11/2023 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: HUBER AVENUE HOME, THE
FACILITY NUMBER: 306004234

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80077.3(a)(3)(C)
Care for Clients who Lack Hazard Awareness or Impluse Control
(C) Following the disaster and mass casualty plan specified in Section 80023, fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all facility staff who provide or supervise client care and supervision.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the Administrator did not comply with the section cited above in that LPA reviewed the facility files and noted that the last fire drill with staff and clients was conducted on 08/01/2023 which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 12/20/2023
Plan of Correction
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Administrator shall ensure that staff and clients participate in the fire/emergency drill quarterly. Administrator will submit in-service training for fire/emergency drill as well as medication training along with topics discussed, dated and signed by staff to CCL/LPA by 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:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2023


LIC809 (FAS) - (06/04)
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