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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191592599
Report Date: 03/16/2022
Date Signed: 03/22/2022 07:37:09 PM


Document Has Been Signed on 03/22/2022 07:37 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:FOUNDERS HOUSE OF HOPEFACILITY NUMBER:
191592599
ADMINISTRATOR:CRYSEL SANTOSFACILITY TYPE:
735
ADDRESS:18025 PIONEER AVE.TELEPHONE:
(562) 860-3351
CITY:ARTESIASTATE: CAZIP CODE:
90701
CAPACITY:98CENSUS: 77DATE:
03/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Crysel Santos -Administrator TIME COMPLETED:
12:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Wong conducted an annual required visit. LPA met with Administrator- Crysel Santos and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures and observed food supply. Facility has submitted a mitigation plan and was approved on 03/17/2021

The facility is licensed to serve 98 mental disabled adults between aged 18-59 years old and ambulatory only. The facility is operating within the scope of it's license. The facility is a two story residence which consists of 51 client rooms. 35 clients rooms are downstairs and 12 clients rooms are upstairs. There are 36 bathrooms downstairs and 13 bathrooms upstairs. The showers are jack and jill showers and on each side of the showers there are clients of the same sex. The facility also consists of reception, staff office, activity room, medication room, dining area, kitchen and laundry room. There's a three side of shared open patio/gym and parking lot with a smoking area in the back of the facility. Each clients room has two beds. There are about four single rooms in the facility (Rm#18, #38, #40 and #51). During the visit, LPA toured Rm#1, #4, #8, #10, #38, #40, #41 and #50) Each clients room has a smoke detector, bed, linen, dresser, light, and sufficient closet space. LPA observed the shower in Rm#1 and there's a big hole on top of the ceiling. Hot water temperature was measured between 88.9 degrees and 103.4 degrees F which is not met the range of Title 22 regulation. LPA toured kitchen and viewed food supply both perishable and non perishable to be within requirements. All the cleaning supplies and sharp utensils are locked and inaccessible to clients. Clients medication are centrally stored and locked in the medication room. LPA inspected the smoke detectors and carbon monoxide detectors and they are operated properly.

Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, facility is disinfected every shift or as needed, restrooms have sufficient soap, paper towels, and signs, facility has an isolation room and PPE supplies are stored for more than 30 days. (See LIC 809C)
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2022
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 3


Document Has Been Signed on 03/22/2022 07:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: FOUNDERS HOUSE OF HOPE
FACILITY NUMBER: 191592599

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
80087 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
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Based on LPA's observation, LPA observed there's a big hole up on the ceciling shower room in Room#1 which poses/posed a potential health, safety or personal rights risk to persons in care.n
POC Due Date: 03/30/2022
Plan of Correction
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The administrator will ensure the facility shall be clean and in agood repair at all times. The administrator will send picture of the shower room in Rm#1 for the repairment. LPA went back to the shower room in Rm#1 and its corrected by putting the tile back up on the ceciling.
Type B
Section Cited
CCR
80088(e)(1)
80088 Furniture, Fixtures, Equipment, and supplies (e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water.
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, LPA observed the hot water was meausred for Rm# 1, #4, #8, #10, #38, #40, #41 and #50 are between 88.9 to 103.4 poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/23/2022
Plan of Correction
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The administrator will fix the hot water temperature immediately and send the hot water log for 7 days to 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: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: FOUNDERS HOUSE OF HOPE
FACILITY NUMBER: 191592599
VISIT DATE: 03/16/2022
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The following deficiencies are cited under the California Code of Regulations Title 22 Division 6 Chapters 1 and documented on the attached LIC 809D

Exit Interview Conducted. A copy of the report and appeal right was provided to Administrator Crysel Santos.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3