191601199-5-18-2023-11-AS-PSCT-CRXT88-20230518142955

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191601199
Report Date: 05/18/2023
Date Signed: 05/18/2023 02:30:00 PM

Document Has Been Signed on 05/18/2023 02:30 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-RENE FAMILY CARE		FACILITY NUMBER:	191601199
ADMINISTRATOR:	RENTERIA, DIANA L.		FACILITY TYPE:	735
ADDRESS:	24231 AMBASSADOR PLACE		TELEPHONE:	(310) 539-3345
CITY:	HARBOR CITY	STATE: CA	ZIP CODE:	90710
CAPACITY: 6		CENSUS: 3	DATE:	05/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:04 PM
MET WITH:	Diana Renteria		TIME COMPLETED:	03:00 PM

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On 05/18/2023, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced annual required visit using the new CARE Inspection Tool. LPA met with Administrator, Eve Tighe and explained the purpose of today’s visit. The facility is licensed to operate for (6) ambulatory (developmentally disabled or Mentally Ill) adults ages 18 through 59. Currently, the home has (3) clients. The clients are Harbor 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 due on 05/23/23, with a balance of $1,135.00.

The facility is single story structure located in a residential neighborhood. It consists of the following: three (3) client rooms, two (2) client bathrooms, one staff room used for office space as well, one (1) living area, one (1) dining area, kitchen, and outside patio area with a table and umbrella for shade.

LPA and Ms. Tighe toured the physical plant. 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 provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 116.4 degrees. The laundry area is located next to the kitchen. Documents are posted as mandated by the DPH and CCLD.

LPA conducted a records review of (3) residents records, (6) 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. LPA reviewed (3) Client Medication Administration Records and did not observe any discrepancies at the time of visit.

Report continued on LIC809-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023

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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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-RENE FAMILY CARE	FACILITY NUMBER: 191601199
	VISIT DATE: 05/18/2023

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LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies and toxins were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly. There are two (2) fire extinguishers fully charge, one (1) in the kitchen and one (1) at the end of the hallway, smoke detectors and carbon monoxide were operable. The last fire/emergency drill was conducted on 04/17/2023.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents. Sanitizing stations (Located in common areas and restrooms) were stocked with masks, gloves, and sanitizers. LPA observed staff were wearing face coverings and LPAs temperature was taken upon entry. LPA observed the facility to have a 90-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) for any updates relating to COVID-19 guidance and other advisories.

During today’s visit there were no deficiencies observed.

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to administrator, Eve Tighe.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023

LIC809 (FAS) - (06/04)

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