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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191600333
Report Date: 08/29/2024
Date Signed: 09/05/2024 04:19:50 AM

Document Has Been Signed on 09/05/2024 04:19 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:C-H #2 COMMUNITY LIVING RESIDENTIAL FACILITYFACILITY NUMBER:
191600333
ADMINISTRATOR/
DIRECTOR:		DAVID BERRYFACILITY TYPE:
735
ADDRESS:3220 W 111TH PLTELEPHONE:
(310) 419-7434
CITY:INGLEWOODSTATE: CAZIP CODE:
90303
CAPACITY: 6CENSUS: 4DATE:
08/29/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Ana Leticia Hernandez TIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced required 1-year visit with the primary focus on Infection Control measures and using the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA was properly screened for COVID-19 symptoms and LPA temperature was checked. LPA Bunker met with staff member Ana Leticia Hernandez and spoke to Licensee Maxine Hartwell via telephone. LPA Bunker explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved mitigation plan report. There are currently four (4), Westside Regional Center Adult Residential Care Facility (ARF) consumers in placement. The facility's annual fees are current.

The following 12 Domains will be observed and reviewed: Infection Control, Physical Plant & Environmental, Operational Requirements, Staffing, Personnel Records-Training, Client Rights-Information, Client Records-Incident Reports, Food Service, Health-Related Services, Incidental Medical Services, Disaster Preparedness, and Emergency Intervention. "I will be using this tool and methods that have been developed to improve the efficiency and accuracy of the Department of Social Services' facility inspections."

The facility is a single-story-family home located in a residential neighborhood. Ms. Hernandez and LPA Bunker toured the facility which consisted of the following: Living room, dining area, kitchen, 4 bedrooms, 2 bathrooms, family room, laundry area, shaded area, indoor/outdoor activity areas, and a detached garage. The front and back yard landscape is in good condition at the time of the visit.

See continued LIC809-C page 2
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: C-H #2 COMMUNITY LIVING RESIDENTIAL FACILITY
FACILITY NUMBER: 191600333
VISIT DATE: 08/29/2024
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Continued LIC9099-C page 2

LPA Bunker observed the facility’s infection control practices, screening protocols for residents and visitors, sanitizer, visitor log, and thermometer at the facility entrance. Logs of daily COVID-19 screening and temperature checks of clients and staff were available and updated. PPE supplies are readily available to staff, and an additional supply of Personal Protective Equipment (PPE) was observed. Sufficient liquid soap, paper goods, cleaning, and disinfecting supplies were observed.

Documents are posted in the living room and hallway. Medications are locked in the hallway cabinet and records are current. Common areas observed for the ability to safely serve the needs of the residents, including cleanliness, and clear of any potential hazards to the residents. The first aid kit is fully stocked with manual, smoke, and carbon monoxide detectors are in compliance, the hot water temperature was measured at 112 degrees Fahrenheit, the fire extinguishers are fully charged, adequate linen supply, the facility telephones are working, and resident's bedroom windows have no sliding window lock with thumbscrew, all exit doors were in compliance, yard free of debris hazards, and trash cans were covered.

The last Fire/Emergency Drill was conducted on June 25, 2024.

Staff was given training on dependent adult and elder abuse reporting video.

There were no deficiencies cited.

Exit interview conducted.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC809 (FAS) - (06/04)
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