Facility Evaluation Report

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required-1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Carmelita Bernardo, Direct Support Professional I & II (DSP I & II), Maria DeCaballero, Direct Support Professional I & II (DSP I & II) and explained the purpose of the visit. At 10:30am, Monique Jordan, Administrator arrived and assisted LPA with the inspection. The facility is licensed to care for twenty two (22) Developmentally Disabled Adults ages 18 through 59, ambulatory only. All clients residing at this facility receive case management services provided by Frank D. Lanterman Regional Center. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Staff clean and disinfect surfaces in the common areas on a regular basis. Staff are trained in the proper use of all required PPEs. Staff are adhering to infection control requirements.

Physical Plant/Environment Safety: The facility is a 2 story home located in a residential neighborhood, contains a total of (11) client bedrooms, of which (4) are located downstairs, and (7) are located upstairs, (5) bathrooms, of which (3) are upstairs and (2) are downstairs , office/storage supplies room, a living room, dining area, kitchen, backyard, front porch with shaded sitting area and detached garage next to a laundry area. Currently, there are (9) clients living in the facility. The interior and exterior physical plant was inspected. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, chair and sufficient closet space. Carbon monoxide operable, smoke detectors/ fire alarms are hard wired to the Fire Department of Pasadena. LPA observed that there is no window covering in bedroom #3. The floor tiles in bathroom #1 are chipped and broken. Bathroom #3 upstairs has mold/mildew in the shower area. Exit doors are free of any obstruction and there are no pools or large bodies of water. Backyard was inspected and the area provides outdoor furniture and shade. LPA observed that one of the garage doors was broken, and ceilings are damaged with severe cracks. Cleaning supplies, and toxic substances are locked in the storage cabinet along with medication. There are (4) fire extinguishers observed which were last serviced on 08/30/2023. There are no firearms or weapons stored at the facility. Facility does not have a video camera monitor system. Water temperature readings measured were not within the required 105 - 120 degrees Fahrenheit. At 9:45am, hot water supply measured at 123.4 deg F in bathroom #1, 123.9 deg F in bathroom #2 and 126.6 deg F in bathroom #4 upstairs. At 12:45pm, LPA re-measured the hot water temperature and are now within the required 105-120 deg F.

Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. A fire clearance is in place. Surety Bond Insurance with bond amount of $18000 is valid and will expire on 01/13/2025. Last Fire Drill wa s conducted on 06/24/2024 and according to the Interim Administrator, emergency drills a re conducted on a monthly basis. *****REPORT CONTINUED ON LIC809-C****