366405847-1-9-2024-56-AS-ACON-CZC2W2-20240109164449

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366405847
Report Date: 01/09/2024
Date Signed: 01/09/2024 04:44:59 PM

Document Has Been Signed on 01/09/2024 04:44 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	HOWARD HOME		FACILITY NUMBER:	366405847
ADMINISTRATOR:	TOLENTINO, LILIAN MA.		FACILITY TYPE:	735
ADDRESS:	4361 HOWARD AVENUE		TELEPHONE:	(909) 627-2546
CITY:	MONTCLAIR	STATE: CA	ZIP CODE:	91763
CAPACITY: 6		CENSUS: 6	DATE:	01/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Francis Pastorfide, Administrator		TIME COMPLETED:	04:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Amber Coleman arrived at the Howard Home, Adult Residential Facility, unannounced to conduct the Annual Inspection. LPA was greeted by Staff Member, Patrice Amon and invited inside the facility. Mr. Amon contacted Administrator, Francis Pastorfide, who arrived last during the visit. Mr. Amon and Mr. Pastorfide accompanied LPA on a tour of the facility. LPA conducted a general overall inspection, which included, but was not limited to, the following: Physical Plant: Mr. Amon reported that the current census is, six, (6) Pathways throughout the facility were free of clutter and obstructions. The facility was maintained at a comfortable temperature. LPA inspected resident bedrooms; each were equipped with required furniture such as: mattresses with adequate linens, night stands, storage space, seating, and sufficient lighting. At approximately 3:05pm LPA inspected resident bathrooms. LPA observed Bathroom #1 along the baseboard was caved in and black and brown in color. At approximately 3:10pm LPA observed Bathroom #2. Inside of the private toilet room the toilet seat was missing and leaned up against the wall. Shower rod and shower curtain was observed to be covered in brown residue. Additionally, underneath the bathroom sink, the bottom appeared to have significant damage. Administrator agreed to have the facility's maintenance staff assess the damages and address them as soon as possible. Each bathroom did have adequate lighting, paper products and working appliances. The facility is equipped with functional smoke/fire detectors and carbon monoxide alarms; which were tested during the visit. Along the walls of the facility, LPA observed posters for resident personal rights, Emergency Plan and contact information, If you see something say something, and house rules, activities calendar and food menus and infection control. LPA verified that medications, cleaning supplies, toxins, sharps, and other dangerous items were kept in secure locations; inaccessible to clients. There was a designated storage space for client/staff files within the designated staff area - adjacent to the Living Room. The facility had emergency food rations, water supplies and first aid kits accessible to those who may need them in case of an emergency. Please see LIC809-C

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: HOWARD HOME	FACILITY NUMBER: 366405847
	VISIT DATE: 01/09/2024

NARRATIVE

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Food Service: Non-perishable and perishable food supply is sufficient for number of residents residing in the facility at this time. Facility has a variety of food available such as frozen meals, meats, fruits, water, milk bread and eggs. LPA also observed adequate amounts of dishware, cups, and utensils were also stored properly. Emergency food and water were also observed in the facility's attached garage.
Care & Supervision: Facility has care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have been cleared for criminal record clearance through the department.
Record Review: LPA reviewed 4 client files for admission agreements, updated physician reports, and needs and services plans. LPA confirmed all regulated documents were maintained in resident files. LPA also reviewed staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings.

Based on observations and interviews, deficiencies will be cited per Title 22, California Code of Regulations to address the above mentioned concerns. A copy of this report was read/reviewed with Administrator, Francis Pastorfide; signature acknowledges understanding and receipt of report and attachments.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/09/2024 04:44 PM - It Cannot Be Edited

Created By: Amber Coleman On 01/09/2024 at 04:25 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: HOWARD HOME	FACILITY NUMBER: 366405847
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations, the licensee did not comply with the section cited above by not addressing various items in disrepair at the facility which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/09/2024
	Plan of Correction
1 2 3 4	Administer agrees to fix the motd in Resident Bathroom #1, have the toilet seat fixed and reattached to the toilet seat, replace the maltfunctioning shower rod, address the broken wood in the resident's closet, replace the damaged window screen and keep the cabinet under the sink secure until the damage can be fixed or replace. Administrator agrees to address these concerns and submit proof to the Community Care Licensing Office within the next 30 days.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Nedra Brown

LICENSING EVALUATOR NAME:

Amber Coleman

LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

LIC809 (FAS) - (06/04)

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