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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191591729
Report Date: 09/25/2023
Date Signed: 09/25/2023 10:52:19 AM

Document Has Been Signed on 09/25/2023 10:52 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:C.M.A.FACILITY NUMBER:
191591729
ADMINISTRATOR:AMARSINGHE, SWARNAFACILITY TYPE:
735
ADDRESS:18432 GRIDLEY RD.TELEPHONE:
(562) 860-2479
CITY:ARTESIASTATE: CAZIP CODE:
90701
CAPACITY: 48CENSUS: 47DATE:
09/25/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Swarna AmarsingheTIME COMPLETED:
11:30 AM
NARRATIVE
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On 9/25/2023 at 9:00 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced visit for an annual continuation. Upon arriving at the facility, LPA met with the Administrator / Swarna Amarsinghe and explained the reason for the visit.

During today’s visit LPA tested the smoke detectors and observed it to be operational. LPA also checked the water temperature, which was measured at 72.5*F-109.4*F respectively which does not meet title 22 guidelines. This poses a potential safety hazard to the clients in care. LPA also observed the broken closet door in room #6 and the broken dresser in the room #1 of the last building was repaired. The toxins was also observed to be locked and secured.

Pursuant to Title 22 code of regulations, the following deficiencies were cited (refer to LIC 809-D): Exit Interview Conducted with licensee / Appeal Rights Provided / A Copy of the Report Issued.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 09/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2023
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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Document Has Been Signed on 09/25/2023 10:52 AM - It Cannot Be Edited


Created By: Jewel Baptiste On 09/25/2023 at 10:32 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: C.M.A.
FACILITY NUMBER: 191591729

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when toxins was left unsecured in the kitchen which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2023
Plan of Correction
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The facility has cleared the deficency by securing all toxins. LPA observed the correction during todays visit.
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 3 bathrooms temperature was under 105. F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/01/2023
Plan of Correction
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The facility will ensure water temperatures in all bathrooms are in complainace with title 22 regulation. The facility will provide LPA with a temperature log for 1-week, by POC due date.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/25/2023 10:52 AM - It Cannot Be Edited


Created By: Jewel Baptiste On 09/25/2023 at 10:32 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: C.M.A.
FACILITY NUMBER: 191591729

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 2 rooms had a broken closet draw or dresser, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2023
Plan of Correction
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During todays visit LPA observed the facility repaired the closet door and dresser. The deficeny was cleard during the visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lisa Hicks
LICENSING EVALUATOR NAME:Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2023


LIC809 (FAS) - (06/04)
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