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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191600333
Report Date: 11/09/2022
Date Signed: 11/09/2022 12:58:12 PM

Document Has Been Signed on 11/09/2022 12:58 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:C-H #2 COMMUNITY LIVING RESIDENTIAL FACILITYFACILITY NUMBER:
191600333
ADMINISTRATOR:DAVID BERRYFACILITY TYPE:
735
ADDRESS:3220 W 111TH PLTELEPHONE:
3104197434
CITY:INGLEWOODSTATE: CAZIP CODE:
90303
CAPACITY: 6CENSUS: 3DATE:
11/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:43 AM
MET WITH:Elsa Rodriguez - CaregiverTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Mario Leon made an unannounced inspection to C-H #2 Community Living Residential Facility. The purpose of today’s visit was to conduct an Annual inspection with a primary focus on infection control measures. During today’s visit, LPA Leon met with caregiver Elsa Rodriguez and the reason for the visit was explained. The facility has a capacity of 6 clients. The facility currently has 3 clients.

LPA Leon toured the facility along with caregiver Elsa Rodriguez. The home consists of 3 client bedrooms, 2 bathrooms, 1 staff bedroom and 1 staff bathroom, living room, Kitchen, dining area and laundry area. All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Walls and floors were clean and in good repair. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation and both had adequate equipment for physically handicapped clients. Toilets and water faucets worked properly. Showers were free of mold/mildew, adequate lighting, and sufficient toiletries were accessible to clients. LPA Leon observed cleaning solution Windex under the sink in bathroom #2. Water temperature was properly measured at 115.1 degrees F in the kitchen.

Non-perishable food supply was checked and adequately stocked at time of visit while perishables need restocking. Carbon monoxide detector was operational. Smoke detectors were working properly, fire extinguisher was fully charged and operational, toxins and sharps were locked and inaccessible to clients. Medications were locked and inaccessible to clients, first aid kit was checked and in order. Outside grounds were toured and no bodies of water were observed. Shaded area in backyard was accessible. Exits/ Walkways around the home were free of debris and hazards.

See LIC809C

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
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: C-H #2 COMMUNITY LIVING RESIDENTIAL FACILITY
FACILITY NUMBER: 191600333
VISIT DATE: 11/09/2022
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During the visit, LPA Leon observed the facility infection control practices. LPA Leon observed screening protocols for visitors, staff and residents, sanitizing stations need updating. LPA observed staff were wearing face coverings, an isolation room and required postings were throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

LPA advised the caregiver to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

During today’s visit there were two deficiencies observed, see LIC809D. Technical assistance notes were provided regarding perishable food supply and screen door to the back door, please see LIC9102.

Exit interview held. A copy of the report was provided to Elsa Rodriguez.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 11/09/2022 12:58 PM - It Cannot Be Edited


Created By: Mario Leon On 11/09/2022 at 12:33 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: C-H #2 COMMUNITY LIVING RESIDENTIAL FACILITY
FACILITY NUMBER: 191600333

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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 LPA Leon observing the windex below the sink in bathroom #2, the licensee did not comply with the section cited above in section 8087(g) while having the toxin accessible to clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/09/2022
Plan of Correction
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Caregiver Elsa Rodriguez immediately removed the windex and placed in in the locked cabinet which is inaccessible to clients in care.
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Leon's observation, the licensee did not comply with the section cited above in having all screens properly repaired which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/16/2022
Plan of Correction
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After speaking with Director David Berry, we have agreed that the facility will be able to fix the back screen within the following week.
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:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2022


LIC809 (FAS) - (06/04)
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