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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530082
Report Date: 07/28/2024
Date Signed: 07/28/2024 12:33:08 PM

Document Has Been Signed on 07/28/2024 12:33 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:ALOHA DUMOND HOMEFACILITY NUMBER:
365530082
ADMINISTRATOR/
DIRECTOR:		TALLA, OMARFACILITY TYPE:
735
ADDRESS:7888 DUMOND DRTELEPHONE:
(626) 675-7256
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 4CENSUS: 3DATE:
07/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Licensee/Administrator Omar TallaTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
NARRATIVE
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On 07/28/2024 at 08:40 AM, Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection to the facility. LPA Brown was greeted by a staff and gained access at the home. Licensee/Administrator Omar Talla was contacted and informed of the visit and arrived during the visit. LPA Brown explained the purpose of the visit to Licensee/Administrator Talla.

The facility has four (4) bedrooms, two (2) bathrooms, kitchen, dining room, living room, attached garage, and backyard. The facility is vendorized by Inland Regional Center (IRC). LPA Brown completed a walkthrough of the facility, review of records, and P& I and medications audit.



Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPA Brown observed three (3) clients during the visit. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 74 degrees Fahrenheit. LPA Brown inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, chairs, and sufficient lighting. LPA Brown inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperature tested at 108 degrees Fahrenheit. The facility is equipped with operational combined smoke detectors and carbon monoxide detectors, charged fire extinguisher, and first aid kit with first aid book.

Posters such as; the personal rights, CCLD complaint poster, labor laws, and emergency disaster plan were posted in a common area. Client medications were kept in secure cabinets inaccessible to clients. LPA Brown observed night lights at the hallway leading to clients' shared bathrooms. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility.
*** Continuation in LIC809C ***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2024
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
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: ALOHA DUMOND HOME
FACILITY NUMBER: 365530082
VISIT DATE: 07/28/2024
NARRATIVE
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LPA Brown observed one (1) sharp scissor not locked in the kitchen drawer and accessible to clients in care. Also, during the tour of the facility, LPA Brown observed one (1) sharp gardening tool in the bakyard, not locked and accessible to clients in care. Deficiency will be issued. In addition, LPA Brown observed two (2) window screens in disrepair. Deficiency issued.

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, attached two (2) car garage observed. All outdoor pathways were free of obstructions.

Food Service: LPAs 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 three (3) client files for admission agreements, medical assessments/physician reports, Individual Program Plan (IPP), Functional Capabilities (LIC9172), Appraisal Needs and Services Plan (LIC625). LPA Brown observed files reviewed were complete. LPA Brown also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result. LPA Brown informed Licensee/Administrator Talla that deficiency will be issued and Civil Penalties were assessed with the amount of $500.00 per individual for Staff #2 (S2) and Staff #3 (S3) working at the facility and the facility did not ensure that their criminal background clearance were transferred to the facility. Also, civil penalty will continue to be assessed of $100.00 per day per citation until corrected. Moreover, LPA Brown observed Staff #3 (S3), and Staff #5 (S5) do not have the required Health Screening Report in their file. Deficiency will be issued. In addition, LPA Brown observed Staff #3 (S3) without the required Tuberculosis (TB) test documents. Deficiency will be issued. Furthermore, LPA Brown observed Staff #3 (S3) without the required on-the-job training maintained in S3 file. Deficiency will be issued.

LPA Brown audited three (3) clients’ medications and no issues were observed. LPA Brown audited three (3) client's P&I and no issue observed.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC421BG and Appeal Rights were discussed, and copies were provided to Licensee/Administrator Omar Talla.

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

DATE: 07/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2024
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 07/28/2024 12:33 PM - It Cannot Be Edited


Created By: Melody Brown On 07/28/2024 at 11:49 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: ALOHA DUMOND HOME
FACILITY NUMBER: 365530082

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 ensuring that the one (1) sharp scissor observed in the kitchen drawer and one (1) sharp gardening tool in the bakyard,
were locked and not accessible to clients in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2024
Plan of Correction
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Licensee stated to train all staff on CCR 80087 (g) and submit proof of training log to LPA Brown on PLan of Correction (POC) due date.
Type A
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

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 ensuring that Staff #3 (S3), and Staff #5 (S5) complete the required Health Screening Report which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2024
Plan of Correction
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Licensee stated to submit Health Screening Medical Appointment/Health Screening Report for S3 and S5 to LPA Brown on 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: 07/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2024


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 07/28/2024 12:33 PM - It Cannot Be Edited


Created By: Melody Brown On 07/28/2024 at 11:49 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: ALOHA DUMOND HOME
FACILITY NUMBER: 365530082

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

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 ensuring that Staff #3 (S3) complete the required Tuberculosis Test with TB Resut maintained in S3 file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2024
Plan of Correction
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Licensee stated to submit proof of Medical Appointment/TB Test with TB Test Result for S3 to LPA Brown on Plan of Correction (POC) due date.
Type A
Section Cited
CCR
80065(f)
Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.

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 ensuring that Staff #3 was provided the required on-the-job training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2024
Plan of Correction
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Licensee stated to submit S3 completed on-the-job training to LPA Brown on 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: 07/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2024


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 07/28/2024 12:33 PM - It Cannot Be Edited


Created By: Melody Brown On 07/28/2024 at 11:49 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: ALOHA DUMOND HOME
FACILITY NUMBER: 365530082

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that the two (2) window screens are in good repair which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2024
Plan of Correction
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Licensee stated to replace the two (2) window screens and submit proof to LPA Brown on Plan of Correction (POC) due date.
Type B
Section Cited
CCR
80019(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or

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 ensuring that Staff #2 (S2) and Staff #3 (S3) criminal background clearance were transferred to the facility prior to employment which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2024
Plan of Correction
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LIcensee stated to transfer S2 and S3 criminal background clearance to the facility and submit proof to LPA Brown on 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: 07/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2024


LIC809 (FAS) - (06/04)
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