191600793-8-24-2023-11-AS-PSCT-CUZUCE-20230824152748

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191600793
Report Date: 08/24/2023
Date Signed: 08/24/2023 03:27:57 PM

Document Has Been Signed on 08/24/2023 03:27 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:	SIMPSON FAMILY HOME		FACILITY NUMBER:	191600793
ADMINISTRATOR:	SIMPSON, ESTELL		FACILITY TYPE:	735
ADDRESS:	18430 COLTMAN AVE		TELEPHONE:	(310) 324-8973
CITY:	CARSON	STATE: CA	ZIP CODE:	90746
CAPACITY: 4		CENSUS: 2	DATE:	08/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Vicki Simpson		TIME COMPLETED:	03:50 PM

NARRATIVE

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On 08/24/23, Licensing Program Analysts (LPAs) Perry Scott and Elvira Gonzalez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with the Vicki Simpson, Administrator, and the purpose of today’s visit was explained. The facility is licensed to operate for (4) ambulatory, (Developmentally Disabled Adults) ages 18 through 59. Currently, the home has (2) clients. The clients are South Central Los Angeles Regional Center clients. None of the clients have Restricted Health Care Conditions and none are utilizing postural supports or protective devices. The facilities annual fees are current.

The facility is a two-story home located in a residential neighborhood. The property consists of the following: 2 client bedrooms, (downstairs), staff bedroom (downstairs), guest room (upstairs), three (3) bathrooms (one bathroom located in staff room and one bathroom located in guest room), living room, kitchen, dining area, attached garage, front porch, laundry room, indoor patio, and backyard.

LPA conducted a records review of (2) client records, (2) staff records, (2) clients Personal & Incidental Records and reviewed the facility disaster plan. All client & Staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPAs reviewed (2) Client Medication Administration Records and observed discrepancies at the time of visit, deficiencies were issued.

LPA toured the physical plant with the administrator. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for resident personal belongings is available. Bed linens, comforters, and bath towels were adequately stocked at the time of the visit. Bathrooms were found to be within Title 22 regulations. Toilets and water faucets worked properly. Shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature measured 113.9 F. A comfortable temperature was maintained in the facility.

Report continued on LIC809-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

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 08/24/2023 03:27 PM - It Cannot Be Edited

Created By: Perry Scott On 08/24/2023 at 02:15 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: SIMPSON FAMILY HOME	FACILITY NUMBER: 191600793
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/24/2023

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. Sharp objects (Knives, Sharp scissors) were observed in a unlocked drawer and bleach was observed in an unlocked cabinet, and were accessible to clients; which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/24/2023
	Plan of Correction
1 2 3 4	Licensee shall ensure that all sharp objects are stored in a locked area in accessible to clients in care at all times. Licensee removed the sharp objects and placed them in a locked cabinet. Deficiency Cleared during time of visit..

Type B

Section Cited

CCR

80075(b)(5)(B)

Health-Related Services

(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. Client 1 missed AM doses of Naproxen 250mg, Famtod 20mg, Hydrocl 25mg, Amlod 5mg, Pioglitaz 30mg, Calcium 600mg, Metform 1000mg, Simvast 10mg, and Benazepril 20mg. Client 2 missed AM dose of Pot Chloride Tab 8mer, Vitamin D3 400I.U, Amplodipine 10mg, Jardiance 10mg, Carvedilol 25mg, Linzess 72mg, Furosemide 40mg, and Metform 40mg which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/29/2023
	Plan of Correction
1 2 3 4	Administrator Vicki Simpson will furnish LPA Perry Scott documentation of completed and authorized medication training by 08/29/23 for all staff, including date of training, those in attendance, dated and signed by all, including administrator. The document is to be emailed to perry.scott@dss.ca.gov by the POC due date of 08/29/23. If not monetary penalties will result.

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:

Janae Hammond

LICENSING EVALUATOR NAME:

Perry Scott

LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

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: SIMPSON FAMILY HOME	FACILITY NUMBER: 191600793
	VISIT DATE: 08/24/2023

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LPA observed the facility to be sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene were stored and not accessible to residents. The kitchen was inspected and there is enough perishable and non-perishable food available at time of visit. Carbon monoxide detector was observed and operational. Smoke detectors were working properly, fire extinguisher was fully charged. LPAs observed that the toxins and sharps were not locked and were accessible to clients, which poses a potential health risk; deficiencies were issued. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. A working landline telephone remains available.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents. LPA observed that sanitizing stations were in common areas and restrooms. LPA observed that the facility had the required postings, posted throughout the facility. LPA further observed the facility to have a 60-day supply of Personal Protective Equipment (PPE).

LPA advised the administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing (www.cdss.ca.gov) for Provider Informational Notices (PIN) and for any updates relating to COVID-19 guidance and other related issues.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did observe deficiencies, therefore citations were issued at this time with plan of corrections to be completed.

Exit interview held and a copy of the report was provided to Vicki Simpson, Administrator.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

LIC809 (FAS) - (06/04)

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