Impact Drug and Alcohol Treatment Center

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Published
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Contact Information
Licensee Name
Principles, Inc.
1680 North Fair Oaks Avenue, Pasadena, CA 91103
Facility Name
Identification Number
190094AN
Reviews & Findings
Dates of Review
5-May-16
Type of Review
COMPLIANCE REVIEW
Deficiencies

1) Section 10563 Accountability Class B

The above section states, in part, “The licensee is accountable for the general supervision of the licensed facility, and for the establishment of policies concerning its operation.”

The provider was deficient in meeting the above regulation because resident was under the influence when admitted and there is no supporting documentation indicating the resident was physically checked every 30 minutes for the first 12 hours following admission.

2) Section 10564(1)(3)(8) Personnel Requirements Class B

The above section states, in part, “Personnel records for staff who provide counseling services (as defined in Section 13005) shall also contain:A copy of the code of conduct of the registrant’s or certified AOD counselor’s certifying organization.”

The provider was deficient in meeting the above regulation because the personnel files for employees #1, #2, #3, #4, #5, #6, #7, #8, #10, #11, #13, #14, and #15 did not contain a signed copy of the code conduct from the certifying organization (CCAPP or CAADE).

3) Section 10581(a) Buildings and Grounds Class C

The above section states, “Facilities shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors.”

The provider was deficient in meeting the above regulation because:
Room29
a. The light fixture in the bathroom is not working.

Room 31
b. The ceiling fan is damaged.
Women’s Bathroom
c. The fan is not working.

4) Section 10584(f)(1) Fixtures, Furniture, Equipment and Supplies Class C

The above section states, in part, “All container’s used for storage of solid waste shall have tight-fitting covers.”

The provider was deficient in meeting the above regulation because the garbage cans in the kitchen and bathrooms did not have tight-fitting lids.

Deficiencies 2

1) Section 16020 Residential Detoxification Practices

The above section states, in part, “Each individual shall be closely observed and physically checked at least every 30 minutes during the first 12 hours following admission by a staff person.”

The provider was deficient in meeting the above standard because resident was under the influence at admission and there is no supporting documentation indicating the resident was physically checked every 30 minutes for the first 12 hours following admission.

2) Section 17010(e)(8) Program Policies

The above section states, “All program policies and procedures shall be contained in an operation manual that is located at each certified site and that shall be available to staff and volunteers. The policies and procedures manual shall contain: Policies and procedures for 8) Detoxification services.”

The provider was deficient in meeting the above standard because the operations manual did not contain information regarding the levels of detoxification services provided, referral plans after, detoxification staffing ratios, and training for detoxification staff. [See Standard; Sections 16D06, 16010, 16015, 16020, 16025 and 16030]

3) Section 26010(a) Health and Safety

The above section states, in part, “Programs shall be clean, safe, sanitary and in good repair”

The provider was deficient in meeting the above standard because:

Room 29
a. The light fixture in the bathroom is not working.
Room 31
b. The ceiling fan is damaged..
Women’s Bathroom
c. The fan is not working.

Detailed Information
Census Data

TOTAL OCCUPANCY:
Approved: 130
Census: 89

TREATMENT CAPACITY:
Approved: 130
Census: 89