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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601228
Report Date: 09/12/2024
Date Signed: 09/12/2024 04:25:09 PM

Document Has Been Signed on 09/12/2024 04:25 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:VERMONT CARE CENTERFACILITY NUMBER:
198601228
ADMINISTRATOR/
DIRECTOR:		ARLENE BARRIOSFACILITY TYPE:
735
ADDRESS:1316 S. VERMONT AVE.TELEPHONE:
(213) 384-1682
CITY:LOS ANGELESSTATE: CAZIP CODE:
90006
CAPACITY: 76CENSUS: 53DATE:
09/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:46 AM
MET WITH:Jeanine Machado Office Manager TIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Tyler Reyes conducted an unannounced Required 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to Office Manager Jeanine Machado of the facility and was granted access into the facility. There are fifty-three (53) ambulatory mentally disabled clients who reside in the home.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention.

LPAs was only able to work on the following domains


Infection Control:

· Infection control practices and Personal Protective Equipment (PPE) were observed.


Physical Plant/Environment Safety:

· The facility is comprised of two buildings (a Main Building and a secondary building known as “Building B”) that are both two-stories located in a residential neighborhood that is licensed for a capacity of seventy-six (76) mentally disabled clients. It consists of fifty-two (52) total client bedrooms, an activity room, dining room, a kitchen, and (2) men and (2) women restrooms. Men's restroom on the first level measured at 88.3 degrees f. Woman's restroom on the first level measured at 87.8 degrees f. Men's restroom on the second floor measured at 83.6 degrees f. Woman's restroom on the second floor measured within the required limit of 105-120 degrees f at 105 degrees f. In Building B the restroom on the first floor measured at 80.0 degrees f. and the restroom on the second floor measured at 80.2 degrees f. The back patio area which contains the facility’s laundry machines LPA Reyes observed with Office Manager Jeanine (2) full Clorox Bleach bottles unattended and accessible to clients. LPA Reyes observed with Office Manager Jeanine in the kitchen underneath the commercial food prep table in a stainless steal container a Reid spray can. In addition LPA Reyes observed underneath the commercial food prep table a bucket of sharps (4) kitchen knives and (1) scissor.



--Continued LIC 809-C--
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Tyler Reyes
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2024
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: VERMONT CARE CENTER
FACILITY NUMBER: 198601228
VISIT DATE: 09/12/2024
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During the tour of the physical plant LPA Reyes observed in (2) randomly selected rooms Room #8 and Room #19 a broken signal alarm. Exit doors are free of any obstruction and there are no pools or large bodies of water. Fire alarm and carbon system is operational.

Operational Requirements:
· The Program Design was reviewed.
· Fire clearance was approved by LA County Fire Department for seventy-six (76) clients.
· Care and supervision to meet the clients’ needs was observed.

Staffing:
· LPA Reyes observed from reviewing the facility's LIC 500 Personnel Report with the Facility Personnel Report Summary that Staff #1 (S1) and S2 are not cleared and associated.

Personnel Records/Staff Training:
· Administrator’s certificate is active and effective through 2/23/2025.
· Five (8) staff files were reviewed.
· Personnel records have health/TB screenings, CPI training, certifications, and 1st Aid/CPR training.

Client Rights/Information:
· Physician orders were reviewed in client files.

Client Records/Incident Reports:
· Five (5) client files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Tyler Reyes
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: VERMONT CARE CENTER
FACILITY NUMBER: 198601228
VISIT DATE: 09/12/2024
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Food Service:
· The kitchen was inspected and has sufficient supply of 2-day .perishable & 7-day non-perishable food.

· No restricted Health Care plan required for the clients in the facility.

Health Related Services:
· Clients are assisted with self-administration of prescription and non-prescription medications.
· Five (5) centrally stored resident medication records were reviewed. Centrally stored medications are kept in a safe and locked place not accessible to clients in care. Medications are given according to Physician directions. Based on LPA Reyes's review of Client #1 (C1) Medication Sheet for the month of September 2024.LPA Reyes observed C1's medications were still in the Bubble Pack and the September 2024 was initial by staff as medication were administered, therefore staff did not administer C1's medication per physician order for C1's medication listed below.

C1's AM Medication - Metformin HCL 500 MG Tablet (Take 1 Tablet by Mouth Twice Dailiy with Meals) were still in the bubble pack for the following dates: 9/11/24

C1's PM Medication - Olanzapine ODT 20 MG Tablet ( Dissolve 1 Tablet By Mouth At Bedtime) were still in the bubble pack for the following dates: 9/11/24

Based on LPA Reyes's review of C2 Medication Sheet for the month of September 2024.LPA Reyes observed C2's medications were still in the Bubble Pack and the September 2024 was initial by staff as medication were administered, therefore staff did not administer C2's medication per physician order for C2's medication listed below.

C2's PM Medication - Clonazeram 1 MG Tablet ( Take 1 Tablet by Mouth Every Evening) were still in the bubble pack for the following dates: 9/2/24 - 9/9/24

C2's PM Medication Risperidone 3 MG Tablet ( Take 1 Tablet by Mouth Every Night at Bedtime) were still in the bubble pack for the following dates: 9/2/24 - 9/9/24

--Continued LIC 809-C--
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Tyler Reyes
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: VERMONT CARE CENTER
FACILITY NUMBER: 198601228
VISIT DATE: 09/12/2024
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Due to time constraints, LPA will return at a later date to complete all (12) CARE Tool domains. Exit interview conducted with Jeanine Machado Office Manager and a copy of this report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Tyler Reyes
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4