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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191600037
Report Date: 07/22/2023
Date Signed: 07/22/2023 05:09:55 PM

Document Has Been Signed on 07/22/2023 05:09 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:ABAD GROUP HOME IIFACILITY NUMBER:
191600037
ADMINISTRATOR:ROSALIE A. NAVALFACILITY TYPE:
735
ADDRESS:22310 HALLDALE AVENUETELEPHONE:
(310) 212-7909
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 6CENSUS: 4DATE:
07/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Araceli FranciscoTIME COMPLETED:
05:20 PM
NARRATIVE
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On 07/22/2023 at 12:50 PM, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced required annual visit using the new CARE Inspection Tools. Upon arrival at the facility, LPA was met by Araceli Francisco and the purpose of today's visit was explained. LPA verified that the facility has an approved mitigation plan report.

The facility is licensed for four (4) ambulatory clients, 18-59 years of age, developmentally disabled. Currently, there are four (4) clients present during today’s visit. LPA Richard and staff Francisco we both toured the inside and outside grounds of the facility. LPA did not screened for Covid-19 symptoms and temperature was checked.

During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance. PPE supplies are readily available to staff, and an additional 30-day supply of PPE is stored in the garage; sufficient paper, cleaning, and disinfecting supplies were observed.

All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed.

There are no security bars or weapons on the premises. Resident bathrooms were checked, sufficient liquid soap was observed. Toilets and water faucets worked properly, grab bars were secure, the shower was free of mold/mildew, and a non-skid mat was in place. A comfortable temperature was maintained in the facility.

REPORT CONTINUED IN LIC 809C

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ABAD GROUP HOME II
FACILITY NUMBER: 191600037
VISIT DATE: 07/22/2023
NARRATIVE
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 LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Centrally stored medications were observed stored in their originally received containers and kept safe and locked and inaccessible to clients in care. The First Aid kit was available. Two fire extinguishers last serviced on 2/30/2023 were observed. Carbon monoxide detectors were in compliance, the hot water temperature was measured at 116.9F degrees.

Outside grounds were toured, and no bodies of water were observed. Walkways around the home were clear of hazards. Common areas were clean and clear of hazards; doorways were free of obstructions,

LPA observed knives and cleaning supplies are stored in an unlocked kitchen cabinet underneath the sink. S1 stated staff don't lock the cabinet because the padlock key is Broken.

LPA observed staff belongings occupied the client's room. S2 stated staff room is crowded.

Deficiencies are issued and an exit interview is conducted with Staff Araceli Francisco. A copy of the report is provided along with the appeal rights.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/22/2023 05:09 PM - It Cannot Be Edited


Created By: Antonine Richard On 07/22/2023 at 04:46 PM
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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ABAD GROUP HOME II
FACILITY NUMBER: 191600037

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2023

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) (interview) (record review)], the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2023
Plan of Correction
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The Licensee will adhere to Title 22 regulations 80087(g). The Licensee will ensure the facility poison are locked and inaccessible to client. The Licensee will submit correction to LPA via Email. Antonine.Richard@dss.ca.gov
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:Ulysses Coronel
LICENSING EVALUATOR NAME:Antonine Richard
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/22/2023 05:09 PM - It Cannot Be Edited


Created By: Antonine Richard On 07/22/2023 at 04:46 PM
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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ABAD GROUP HOME II
FACILITY NUMBER: 191600037

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85087(a)(4)
Building and Grounds
(4) No client bedroom shall be used as a public or general passageway to another room, bath or toilet.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview)], the licensee did not comply with the section cited above staff belongings occupied client's room which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2023
Plan of Correction
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Staff removed her belongings from the client's room. The licensee will Submit a plan of correction to LPA via email Antonine.Richard@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Ulysses Coronel
LICENSING EVALUATOR NAME:Antonine Richard
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2023


LIC809 (FAS) - (06/04)
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