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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191600793
Report Date: 08/07/2024
Date Signed: 08/07/2024 01:35:39 PM

Document Has Been Signed on 08/07/2024 01:35 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:SIMPSON FAMILY HOMEFACILITY NUMBER:
191600793
ADMINISTRATOR/
DIRECTOR:		SIMPSON, ESTELLFACILITY TYPE:
735
ADDRESS:18430 COLTMAN AVETELEPHONE:
(310) 324-8973
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY: 4CENSUS: 1DATE:
08/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:08 PM
MET WITH:Vicki SimpsonTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 08/07/24, Licensing Program Analyst (LPA) Perry Scott 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 (1) client. The client is a South-Central Los Angeles Regional Center client. The client does not have Restricted Health Care Conditions and is not utilizing postural supports or protective devices. The facilities annual fees are due on 08/24/24 for $454.00.

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 (1) client record, (2) staff records, (1) client Personal & Incidental Record 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 (1) Client Medication Administration Records and did not observe any discrepancies at the time of visit.

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 114.6 F. An emergency/fire drill was completed on 07/01/2024. 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: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2024
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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: SIMPSON FAMILY HOME
FACILITY NUMBER: 191600793
VISIT DATE: 08/07/2024
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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. Smoke and Carbon Monoxide detectors were working properly; fire extinguisher(s) were fully charged and last serviced on 03/08/2024; and toxins and sharps were locked and inaccessible to clients. 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 not observe any deficiencies, therefore no citations were issued at this time.

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: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024
LIC809 (FAS) - (06/04)
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