198200906-5-5-2022-11-AS-JCAS-CE5NTC-20220505104430

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198200906
Report Date: 04/26/2022
Date Signed: 05/05/2022 10:44:43 AM

Document Has Been Signed on 05/05/2022 10:44 AM - 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 DR #100
MONTERY PARK, CA 91754

FACILITY NAME:	ALTIUS II ADULT RESIDENTIAL		FACILITY NUMBER:	198200906
ADMINISTRATOR:	PEDRO PEREZ		FACILITY TYPE:	735
ADDRESS:	3745 W. 157TH STREET		TELEPHONE:	(310) 973-8249
CITY:	LAWNDALE	STATE: CA	ZIP CODE:	90260
CAPACITY:	6	CENSUS: 4	DATE:	04/26/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Maricela Pacheco		TIME COMPLETED:	03:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Jey Cardenas conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA was met with DSP staff Maricela Pacheco, LPA conducted a risk assessment, based on the assessment, the facility is clear of Covid-19 infection. LPA verified that the facility has an approved mitigation plan report. The facility is licensed for six (6) clients, ambulatory only, prefers to serve developmentally disabled adults ages 18 thru 59 years.

LPA and Pacheco both toured the inside and outside grounds of the facility. LPA was properly screened for Covid-19 symptoms and temperature was checked. The one story residential house consists of the following: 3 bedrooms, office room, 1 & 1/2 bathrooms, living room, kitchen, dining-room, laundry area. There is a shaded outdoor area, and an attached garage.

During the tour, LPA observed the facility’s infection control practices. LPA was pre-screened for covid-19 and temperature was taken at the designated visitors entrance located at the side of the facility. LPA signed visitors log with Covid-19 screening and temperature log. PPE supplies are readily available to staff, and an additional 60-day supply of PPE was observed. Sufficient paper, cleaning, and disinfecting supplies were observed. The facility’s designated visitation area is the shaded backyard patio. LPA observed staff and client maintain 6 feet physical distancing, and all staff wear a face covering.

All rooms were inspected. Beds in shared bedrooms are 6 feet apart/3 feet head-to-toe apart. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed.

Client bathrooms were checked, sufficient liquid soap, LPA was notified that client at facility has been diagnosed with PICA and facility prefers not to have paper towels in bathroom. Facility has plan to ensure clients are provided with paper towels when needed. Toilets and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. The water temperature measured at 105.9

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey Cardenas	TELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022

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, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: ALTIUS II ADULT RESIDENTIAL	FACILITY NUMBER: 198200906
	VISIT DATE: 04/26/2022

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degrees F in client bathroom. Comfortable temperature was maintained in the facility.

LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in a locked storage cabinet located in the office. Centrally stored medications were observed stored in their originally received containers and kept safe and locked and inaccessible to clients in care. The First Aid kit was available and stocked. One (1)Carbon Monoxide and individual Smoke Detectors were tested and operable. The facility (1) Fire Extinguisher was checked, On 4/26/2022 fire extinguisher didn’t have inspection label and a purchase receipt was not available to confirm fire extinguisher was purchased within a year.

Outside grounds were toured, and no bodies of water were observed. Walkways around the home were clear of hazards. Common areas were clean and clear of hazards; doorways were free of obstructions.

Advisory Notes with technical assistance were issued:

Post signage for hand washing in all sinks of the facility.

Deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted and appeal rights discussed. A copy of this report and appeal rights provided to Pacheco.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey Cardenas	TELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/05/2022 10:44 AM - 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 DR #100
MONTERY PARK, CA 91754

FACILITY NAME: ALTIUS II ADULT RESIDENTIAL	FACILITY NUMBER: 198200906
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80020(a)

This requirement is not met as evidenced by: Fire Clearance. All facilities shall secure and maintain a fire clearance approved by the city or county fire department...
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above: On 4/26/2022 LPA observed fire extinguisher didn't have inspection label, nor purchase receipt. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/26/2022
	Plan of Correction
1 2 3 4	Submit picture of new extinguisher with purchase receipt, or have current extinguisher serviced, provide picture of inspected tab.

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: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey Cardenas	TELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022

LIC809 (FAS) - (06/04)

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