191600825-9-21-2023-11-AS-AINZ-CVVTYJ-20230921150848

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191600825
Report Date: 09/21/2023
Date Signed: 09/21/2023 03:08:54 PM

Document Has Been Signed on 09/21/2023 03:08 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:	DIANA'S HOME		FACILITY NUMBER:	191600825
ADMINISTRATOR:	RENTERIA, DIANA LEE		FACILITY TYPE:	735
ADDRESS:	827 GIAN DRIVE		TELEPHONE:	(310) 533-5128
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90502
CAPACITY: 6		CENSUS: 4	DATE:	09/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:57 PM
MET WITH:	Eve Hensey-Administrator		TIME COMPLETED:	03:00 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

On 9/18/2023 Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Eve Hensey /Administrator and the purpose of today’s visit was explained. The facility is licensed to operate for (6) developmentally disabled or Mentally Ill adults ages 18 through 59. The clients are from: Harbor Regional Center. (0) clients have Restricted Health Care Conditions, and (0) are utilizing postural supports or protective devices.

Facility is two story structure located in a residential neighborhood. It consists of the following: three (3) client rooms, two (2) client bathrooms, one (1) staff quarters including a bathroom, one (1) living area, one (1) dining area, one (1) computer area including a separate room for staff/storage, and kitchen. Outside patio area including a shed for storage and a table with an umbrella for shade. There were no bodies of water.

LPA Iniguez and administrator toured the inside and outside of the facility. All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting was observed, plenty of dresser and closet space was observed. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. 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 properly measured between 105F°-120F° degrees (Kitchen 106.5F°, Bathroom #1 106.8°F).

Evaluation Report continues LIC 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

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 3

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: DIANA'S HOME	FACILITY NUMBER: 191600825
	VISIT DATE: 09/21/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide/Smoke detectors were observed and operational. Fire extinguishers were fully charged, knifes were locked and inaccessible to clients. LPA found unlocked cleaner supplies on second floor bathroom under the sink. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Last facility disaster drill was 8/10/2023.

LPA conducted a records review of (2) client records, (2) staff records and reviewed the facility disaster plan. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (2) Client Medication Administration Records (MAR) and did not observe any discrepancies at the time of visit.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8.

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to the Administrator/ Eve Hensey.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 09/21/2023 03:08 PM - It Cannot Be Edited

Created By: Alfonso Iniguez On 09/21/2023 at 02:45 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: DIANA'S HOME	FACILITY NUMBER: 191600825
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/21/2023

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
1 2 3 4	Based on observation the licensee did not comply with the section cited above in keeping cleaning solutions locked which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/22/2023
	Plan of Correction
1 2 3 4	The licensee locked cleaning solutions while LPA was there. As part of the Plan of Correction, the licensee will ensure all cleaning solutions will be locked at all times and do all staff re-training regarding keeping poisons and cleaning solutions locked. The licensee will send proof of training by the POC due date to LPA via email.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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:

Eva M Alvarez

LICENSING EVALUATOR NAME:

Alfonso Iniguez

LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3