Dare U To Care Outreach Ministry

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Contact Information
Licensee Name
Dare U To Care Outreach Ministry
316 West 120" Street, Los Angeles, CA 90061
Facility Name
Identification Number
190182EN
Reviews & Findings
Dates of Review
February 8, 2016'
Type of Review
COMPLIANCE REVIEW
Deficiencies

1) Title 9, Section 10513 Adherence to Express Conditions of Licensure Class B

The above section states, ”A licensee shall not operate a facility beyond the conditions and limitations specified on the license.”

The licensee was deficient in meeting this regulation because the licensee was providing services to clients who were not residents of the facility. Section 10501(a)(22), states, in part, the “Licensee” means the entity identified to provide residential alcoholism or drug abuse recovery or treatment services.”

Section 10501(a)(6), states, in part, “Alcoholism or Drug Abuse Recovery Treatment Facility” means any facility maintained and operated to provide 24-hour residential recovery or treatment services.” A treatment service is defined as group or individual sessions; group session is defined as group interaction with residents (defined below); individual Session is a private interaction between a resident and program staff; Section 10501(a)(16) defines a “Facility” as a residential treatment facility; Section 10501(a)(S) limits the capacity to the maximum number of residents the facility is licensed to provide services; Section 10501(a)(26) defines a resident as a person who resides in and receives services from a residential treatment facility; a “Residential Alcoholism or Drug Abuse Recovery or Treatment Facility” is a facility maintained and operated to provide 24- hour, residential treatment services.

The program schedule documents clients from the home at 305 West 120th Street and residents at 316 West 120th Street are being coming led in group sessions.

2) Title 9, Section 10572(9) Health-Related Services Class C

The above section states, in part, “Prescription medications which are not removed by the resident shall be destroyed by the facility administrator and one other adult. Both shall sign a record, which lists the following: Name of resident, prescription number and name of pharmacy, drug name, strength, and quantity destroyed, date of destruction.”

The licensee was deficient in meeting the above regulation because there are no policies and procedures in place to address the destruction of unused medications.

3) Title 9, Section 10564(e)(1) Personnel Records Class B

The above section states, in part, “good physical health shall be verified by a health screening, including a test for tuberculosis, performed under licensed medical supervision not more than sixty (60) days prior to or seven (7) days after employment with tuberculosis testing renewable every year.

Personnel with a known record of tuberculosis or record of positive testing shall not be required to be retested if a physician verifies the individual has been under regular care and monitoring for tuberculosis. Such verification will be renewed annually.

The licensee was deficient in meeting the above regulation because there was no current tuberculosis test result for employees.

4) Title 9, Section 10564(1)(3)(6) Personnel Requirements Class C

The above section states, in part, “The licensee shall maintain personnel records for all staff. Personnel records for staff who provide counseling services shall also contain: a copy of the code of conduct of the registrant’s or certified AOD counselor’s certifying organization.”

The licensee was deficient in meeting the above regulation because there was not signed copy of the code of conduct of the registrant’s or certified AOD counselor’s certifying organization pursuant to Section 13060 for employees.

5} Title 9, Section 10565(a)(5) Personnel Records Class C

The above section states, in part, “Personnel records shall be complete and maintained for each employee and shall contain the following: past experience, including types of employment and former employers.”

6) Title 9, Section 10565(a)(4) Personnel Records Class C

The above section states, in part, “Personnel records shall be complete and maintained for each employee and shall contain the following duty statement.”

The licensee was deficient in meeting the above regulation because there was no duty statement for employee.

7) Title 9, Section 10565(b) Personnel Records Class C

The above section states, in part, ”All personnel shall have on file the record of the health screening as specified in Section 10564(c)(1)(2) of this chapter.

The licensee was deficient in meeting the above regulation because there was no health screening documents for employees through.

8) Title 9, Section 10569(a)(2) Personal Rights Class C

The above section states, in part, “Each resident shall have personal rights which include,but are not limited to the following: To be accorded dignity in personal relationships with staff and other persons.”

The licensee was deficient in meeting the above regulation because the personal rights document did not include the above statement.

9) Title 9, Section 10572(c) Health-Related Services Class C

The above section states, in part, “First aid supplies shall be maintained and be readily available in the facility. A current edition of a first aid manual approve by the American Red Cross Thermometer.”

The licensee was deficient in meeting the above regulation because there was no first aid manual or thermometer readily available.

10) Title 9, Section 10573(a)(1) Food Service Class C

The above section states, in part, “In facilities providing meals to residents, the following: all food shall be selected, stored, prepared and served in a safe and healthful manner.”

11) Title 9, Section 10573(a)(15) Food Service Class C

The above section states, in part, “Pesticides and other similar toxic substances shall not be stored in food storerooms, kitchen areas.”

The licensee was deficient in meeting the above regulation because there is a cabinet in the kitchen area that stores cleaning products.

12) Title 9, Section 10573(a)(17)(19) Food Service Class C

The above section states, in part, ”All kitchen, food preparation, and storage areas shall be kept clean, free from litter and rubbish.

Measures shall be taken to keep all such areas free from rodents and other vermin. All utensils shall be kept clean.”

The licensee was deficient in meeting the above regulation because there were live and dead cockroaches on the counter top and in drawers, which stored cooking and eating utensils.

13) Title 9, Section 10573(a)(19) Food Service Class C

The above section states, in part, ”All equipment, fixed or mobile shall be kept clean, and maintained in good repair.”

The licensee was deficient in meeting the above regulation because of the following reasons:

• Kitchen stove has baked on grease and needs deep cleaning.
• Light in food pantry area does not work.
• Kitchen floors need deep cleaning.
• Microwave is missing the turntable and needs cleaning.
• Metal screen door to kitchen as grease buildup and needs cleaning and/or repainting.

14) Title 9, Section 10581(a)(3) Buildings and Grounds Class C

The above section states, in part, “Facilities shall be clean. The facility must be separate and secure. Facility living, sleeping, bathing and toiletry areas shall be enclosed by permanent and doors.”

The licensee was deficient in meeting the above regulation because there is a sheet hanging to separate bedroom #1 from bedroom #2.

15) Title 9, Section 10584(c) Fixtures, Furniture, Equipment and Supplies Class C

The above section states, in part, “The licensee shall provide lamps or lights as necessary in all rooms and other areas to ensure the safety of all persons in the facility.”

The licensee was deficient in meeting the above regulation because throughout the facility there are many light fixtures with missing light bulbs, or the lights would not come on during my visit.

16) Title 9, Section 10584(e) Fixtures, Furniture, Equipment and Supplies Class C

The above section states, in part, “All toilets, hand washing and bathing facilities shall be maintained in a safe and sanitary operating conditions.”

The licensee was deficient in meeting the above regulation because of the following:
* Bathroom in bedroom #3:
o Broken floor tile
o Moldy shower curtain
o Listerine bottle (contains alcohol)
* Bathroom located back side of kitchen
o Toilet, sink, mirror, floors all need deep cleaning
o Shower had mold
o Toilet seat needs replacing
o Three exposed light bulbs that need covers
* Bathroom #4 (in bedroom #4)
o Missing light bulbs, exposed bulb receptacles

17) Title 9, Section 10584(g) Fixtures, Furniture, Equipment and Supplies Class C

The above section states, “The licensee shall provide clean linen in good repair, including lightweight, warm blankets, top and bottom bed sheets, pillow cases, mattress pads, bath towels, and wash cloths. The quantity of linen provided shall permit changing at a minimum, once a week or with greater frequency if needed.”

The licensee was deficient in meeting the above regulation because of the following:
* Bedroom #2
o Two beds without pillow cases
o No sheets on one bed

* Bedroom #3
o One bed with no mattress pad
o Two beds with no sheets

Deficiencies 2

1) Section 12070(b)(4)(C) Recovery or Treatment Planning

The above section states, in part, “Staff and the participant shall review and update the treatment plan no later than 90 days after signing the initial treatment plan.”

The provider was deficient in meeting the above standard because of the following:
• Treatment plans had not been updated within 90 days for the residents

2) Section 17010(e)(4)(5)(7}(17) Program Policies

The above section states, in part, “All program policies and procedures shall be contained in an operational manual policies and procedures manual shall contain individual and group sessions; Alumni involvement; recreational activities; and community relations.”

The provider was deficient in meeting the above standard because the policies and procedures manual did not contain the following:

• Policies sand procedures for individual and group sessions
• Policies and procedures for alumni involvement
• Policies and procedures for recreation activities
• Policies and procedures for community relations

3) Section 17015(b)(3)(1) Participant Files

The above section states, in part, “Each participant file shall contain…consent to follow-up.”

The provider was deficient in meeting the above standard because the following participant files did not contain the consent to follow-up form:
• Participants through

4) Section 17015(b)(4)(C): Participant Files
The above section states, in part, “… Closed file data..,consent to follow-up.n

The provider was deficient in meeting the above standard because the following closed files did not contain the consent to follow-up form:

• Discharged files

5) Section 17015(e)(2)(3) Participant Files

The above section states, in part, “There shall be a written policy regarding the maintenance and disposal of participant files. Participant files shall be destroyed in a manner that ensures confidentiality of participants”.

The provider was deficient in meeting the above standard because there was not a policy and procedure for the maintenance and disposal of participant files.

6) Section 19005(a)(4)(E) Personnel Policies

The above section state/s in part, “The program shall establish and maintain personnel policies that contain information about employee safety and injuries.

The provider was deficient in meeting the above standard because the personnel policies did not address employee safety and injuries.

7) Section 19005(b)(1)-(7) Personnel Policies

The above section states, in part, “The program shall maintain personnel files on all employees. Each fife shall contain application for employment and resume, employment confirmation, job description, salary schedule , employee evaluations, health records.. .tuberculosis test results as required,and other personnel actions.”
following employee files:

(1) No resume’ for employees
(2) No job application for employee
(3) No job description for employee
(4) No employment confirmation statement for employees
(5) No salary schedules for employees
(6) No or outdated employee evaluations for employees
(7) No health records for employees
(8) Expired tuberculosis results for employees 1

8) Section 19010(a)(b)(1)-(7) Code of Conduct

The above section states, in part, “The program shall have a written code of conduct shall include the followning: Use of alcohol and/or other drugs on premises; personal relationships with participants; prohibition of sexual contact with participants; sexual harassment; unlawful discrimination; conflict of interest, confidentiality ”

The provider was deficient in meeting the above standard because the code of conduct did not include all the above and needs revision.

9) Section 19010(d) Code of Conduct

The above section states, in part, “Each staff shall sign a copy of the code of conduct the program shall place the signed copy in the personnel file of the individual.”

The provider was deficient in meeting the above standard because the following personnel files did not have signed copies of the code of conduct:
• Employees

10) Section 21000(e) Admission Agreement

The above section states, in part, “The program shall have a written admission agreement. The admission agreement shall inform the participants of participant’s grievance procedure.”

The provider was deficient in meeting the above standard because the admission agreement contains incorrect Department information.

The above section states, in part, “Each participant shall have rights that include to be free from discrimination based on ethnic group identification, religion, age, sex, color, or disability to be accorded access to his or her file.”

The provider was deficient in meeting the above standard because the participant rights document did not include all the above.

12) Section 26010(a) Health and Safety

The above section states, in part, “Programs shall be clean, safe, sanitary and in good repair at all times for the safety and well being of participants, employees and visitors. The program shall be free from: broken glass, filth, litter, insects, or other vermin, toxic chemicals, exposed electrical wiring, broken plaster.”

The provider was deficient in meeting the above standard because of the following:

* Carpets and/or linoleum were filthy throughout the facility.
* Not all bathrooms had toilet paper available.
* Bedroom #1
o Hole in wall needs repairing
o Exposed light bulb, needs cover
o Replace sheet, that separates the two rooms, with a door
* Bedroom #2
o Two beds without pillow cases
o Exposed light bulb, needs cover
o No sheets on one bed
* Bedroom #3
o Floor fan with no cover, exposed fan blades
o One bed with no mattress pad
o Two beds with no sheets
• Bathroom in bedroom #3: o Broken floor tile
o Moldy shower curtain
o Listerine bottle (contains alcohol)
* Bathroom located back side of kitchen
o Toilet, sink, mirror, floors all need deep cleaning
o Shower had mold
o Toilet seat needs replacing
o Three exposed light bulbs that need covers
* Bathroom #4 (in bedroom #4)
o Missing light bulbs, exposed bulb receptacles
* Window sills, throughout the facility are dirty.

• Group Room
o Hole in wall from air conditioner unit being removed.
o Walls dirty, clean or repaint
o Microwaves- one missing turntable, both dirty
o Ceiling fan is missing light bulb
o Exterior-Back side of group room has large hole in the stucco.
• Kitchen
o Stove has baked on food and/or grease
o Refrigerators (kitchen and group room) all need cleaning and remove old food
o Light in the food pantry did not work
o Potatoes were spoiled in the utensil tray on the counter
o Microwave is missing turntable and needs cleaning
o Cockroaches, dead and alive, were present on counters and in drawers with cutlery and dishes
o Kitchen floors need cleaning
o Metal screen door needs cleaning and/or repainting
o There did not appear to be enough dishes, cups, utensils for the capacity licensed.

Detailed Information
Census Data

TOTAL OCCUPANCY:
Approved: 21
Census: 14

TREATMENT CAPACITY:
Approved: 21
Census: 14