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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004656
Report Date: 05/03/2023
Date Signed: 05/03/2023 12:02:56 PM

Document Has Been Signed on 05/03/2023 12:02 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:WELSH GATEFACILITY NUMBER:
306004656
ADMINISTRATOR:PAUL SHAHPARAKIFACILITY TYPE:
735
ADDRESS:3201 ORANGEWOOD AVENUETELEPHONE:
(562) 598-9051
CITY:ROSSMOORSTATE: CAZIP CODE:
90720
CAPACITY: 4CENSUS: 2DATE:
05/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Paul ShahparakiTIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA met with Administrator (AD) Paul Shahparaki and discussed the purpose of the inspection.

During the inspection LPA and AD conducted a tour of the inside and outside of the facility, common areas, client rooms, staff room, kitchen, garage and observed the following:

This is a one-story house with three client bedrooms, three bathrooms, and two staff bedrooms. All client bedrooms had the required furnishings. LPA observed all client beds had linens and blankets. LPA observed all windows were screened. The back yard has a shaded sitting area, and backyard pool was observed to be fenced and secured. LPA observed one staff and two clients present. Clients were observed to be leaving for day program and a walk. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 113.2 and 118.3 F degrees. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted by the telephone at the facility. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients. Medication was observed to be locked, however, was not observed to be in its original container or packaging; two deficiencies were cited on today’s date. LPA reviewed two client files and AD’s personnel file; a Technical Advisory was given on this date. Clients were not present to be interviewed.

Based on the observations made during today’s inspection, two deficiencies is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2023
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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Document Has Been Signed on 05/03/2023 12:02 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 05/03/2023 at 10:40 AM
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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: WELSH GATE
FACILITY NUMBER: 306004656

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(5)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (5) Each client's medication shall be stored in its originally received container.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and AD admission, the licensee did not comply with the section cited above as client medication was observed in a plastic medication organizer indvidually seperated for 14-days. AD stated medication had been transferred from orginal container to medication organizer which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/04/2023
Plan of Correction
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AD stated all medication would be placed back in its original container and will be given a dose at a time and will not be prepared days in advance. AD to provide LPA with picture proof via email by POC date.
Type A
Section Cited
CCR
80075(k)(6)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (6) No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and AD admission, the licensee did not comply with the section cited above as one out of two medications was observed to be expired. AD stated the medication is not expired and had been transferred from original container received to a different container which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/03/2023
Plan of Correction
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AD stated all medication would be placed back in its original container. AD to provide LPA with picture proof via email by POC 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:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2023


LIC809 (FAS) - (06/04)
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