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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360951409
Report Date: 01/26/2024
Date Signed: 01/26/2024 03:31:14 PM

Document Has Been Signed on 01/26/2024 03:31 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:GALONGO MICHAEL HOMEFACILITY NUMBER:
360951409
ADMINISTRATOR:DANCY, BARBARAFACILITY TYPE:
735
ADDRESS:1452 W 5TH STTELEPHONE:
(909) 983-2957
CITY:ONTARIOSTATE: CAZIP CODE:
91762
CAPACITY: 6CENSUS: 4DATE:
01/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Licensee/Administrator Barbara DancyTIME COMPLETED:
11:25 AM
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On 01/26/2024 at 08:40 AM, Licensing Program Analyst (LPA) Melody Brown arrived unannounced to conduct the required comprehensive annual inspection to the facility. LPA met with Licensee/Administrator Barbara Dancy, introduced self and stated the purpose of the visit.

The facility has six (6) bedrooms, four (4) bathrooms, kitchen, dining room, living room. The facility is vendorized by Inland Regional Center (IRC). LPA Brown completed a walkthrough of the facility, review of records, medication audit and P&I audit.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPA Brown observed no client at the facility. Licensee/Administrator Dancy reported that all of their four (4) clients are out in the community. There are no obstructions to indoor and outdoor passageway. The facility is maintained at a comfortable temperature of 71 degrees Fahrenheit. LPA Brown inspected client bedrooms; they are equipped with required furniture such as: mattresses, storage space, chairs, night stands and sufficient lighting. LPA Brown inspected client bathrooms; bathrooms were clean, and appliances were found functional. However, LPA Brown observed (three) client cloth hand towels in the client shared bathroom. Technical Violation issued. Water temperatures tested at 108 degrees Fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide detectors, charged fire extinguishers, and first aid kit with first aid book.

Posters such as; the personal rights, CCLD complaint poster, emergency disaster plan were posted in a common area. Sharps and medications were kept in secure cabinets inaccessible to clients. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility. Overall, the facility is clean, and operates in safe conditions for clients in care. *** Continuation in LIC809C ***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: GALONGO MICHAEL HOME
FACILITY NUMBER: 360951409
VISIT DATE: 01/26/2024
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Yards/Outside: One shaded patio, one (1) side gate with self-latching handle on the left side of the house that leads into the backyard. The outdoor pathway was free of obstruction. LPA Brown observed pool fence gate locked.

Food Service: LPA observed two (2) day(s) supply of perishable food and seven (7) day(s) supply of non-perishables food and snacks. Dishes, cups, and utensils were stored properly.


Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA Brown reviewed four (4) client files for Admission Agreements, Needs and Services Plans, Pre-placement Appraisal, Functional Capabilities, and Physician Report (LIC602). LPA Brown observed that Client #1 (C1), Client #2 (C2), Client #3 (C3) and Client #4 (C4) do not have the Needs and Services Plan and Functional Capabilities and Pre-placement Appraisal in their facility file. Deficiencies will be issued. LPA also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with Tuberculosis (TB) Test result and all staff files were observed complete. LPA Brown reviewed C1, C2, C3 and C4 P&I records and LPA Brown observed no issue. LPA Brown reviewed C2 and C3 medications and observed no issue.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102 and Appeal Rights were discussed and copies were provided to Licensee/Administrator Barbara Dancy.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/26/2024 03:31 PM - It Cannot Be Edited


Created By: Melody Brown On 01/26/2024 at 10:29 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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: GALONGO MICHAEL HOME
FACILITY NUMBER: 360951409

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85077(a)
Personal Services
(a) Licensees shall provide necessary personal assistance and care, as indicated in the needs and services plan, with activities of daily living including but not limited to dressing, eating, and bathing.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not having the required Needs and Services Plan for Client #1 (C1), Client #2 (C2), Client #3 (C3) and Client #4 (C4) maintained in their facility file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2024
Plan of Correction
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Licensee stated to complete the required Needs and Services plan for C1, C2, C3 and C4 and submit proof to LPA Brown at Plan of Correction (POC) due date.
Type B
Section Cited
CCR
80069.2(b)
Functional Capabilities Assessment
(b) Assessment of the client's need for assistance shall include consideration of his/her physical condition affecting participation in his/her own care, including:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not completing the required Functional Capabilities for Client #1 (C1), Client #2 (C2), Client #3 (C3) and Client #4 (C4) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2024
Plan of Correction
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Licensee stated to complete the required Functional Capabilities for C1, C2, C3 and C4 and submit proof to LPA Brown at 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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024


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