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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191601267
Report Date: 09/16/2021
Date Signed: 09/16/2021 11:33:56 AM

Document Has Been Signed on 09/16/2021 11:33 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:C-H COMMUNITY LIVING RESIDENTIAL FACILITYFACILITY NUMBER:
191601267
ADMINISTRATOR:DAVID BERRYFACILITY TYPE:
735
ADDRESS:14708 FRAILEY AVETELEPHONE:
(310) 637-4604
CITY:RANCHO DOMINGUEZSTATE: CAZIP CODE:
90221
CAPACITY: 6CENSUS: 5DATE:
09/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:23 AM
MET WITH:David BerryTIME COMPLETED:
11:54 AM
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Licensing Program Analyst (LPA) Ulysses Coronel conducted an unannounced Annual Required visit with a primary focus on infection control measures. LPA contacted David Berry and Maxine Hartwell. Administrators and the purpose of today’s visit was explained. The facility is licensed to serve clients age range 18 through 59, approved to serve 4 ambulatory clients.

There are currently 5 South Central Los Angeles Regional Center clients in placement. All 5 clients are ambulatory. The facility is a single story structure located in a residential neighborhood. It consists of the following: living room, kitchen, dining area, four (4) bedrooms, two (2) bathrooms, enclosed patio area, patio with chairs and detached two car garage.

LPA and staff toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All passageways inside and outside of the facility were clear of obstructions. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. 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 148.1 F. A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is enough perishable and enough non-perishable food available which are stored properly. Fire extinguisher was charged, smoke and Carbon Monoxide detectors were operable.

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). LPA observed staff and residents were wearing face coverings, an isolation room and required postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2021
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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: C-H COMMUNITY LIVING RESIDENTIAL FACILITY
FACILITY NUMBER: 191601267
VISIT DATE: 09/16/2021
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LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

During today’s visit there were deficiencies observed, Title 22, Chapter 6, Division 1 is being cited, please see LIC809D .

An exit interview held. A copy of the report and appeals rights was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/16/2021 11:33 AM - It Cannot Be Edited


Created By: Ulysses Coronel On 09/16/2021 at 10:55 AM
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: C-H COMMUNITY LIVING RESIDENTIAL FACILITY
FACILITY NUMBER: 191601267

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Furniture, Fixtures, Equipment, and Supplies
Faucets used by clients for personal care such as shaving and grooming shall deliver hot water.
Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above the hot water temperature measured at 148.1 F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/17/2021
Plan of Correction
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The administrator will have the water heater serviced and agreed to create a plan of corrections that will provide staff with specific steps to monitor the hot water temperature and immidiately report concerns to enable administrator to have the equipment fixed on a timely manner.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2021


LIC809 (FAS) - (06/04)
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