191601267-10-19-2024-11-AS-SLEO-DA7TU8-20241019150154

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191601267
Report Date: 10/19/2024
Date Signed: 10/19/2024 03:02:03 PM

Document Has Been Signed on 10/19/2024 03:02 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	C-H COMMUNITY LIVING RESIDENTIAL FACILITY		FACILITY NUMBER:	191601267
ADMINISTRATOR/ DIRECTOR:	DAVID BERRY		FACILITY TYPE:	735
ADDRESS:	14708 FRAILEY AVE		TELEPHONE:	(310) 637-4604
CITY:	RANCHO DOMINGUEZ	STATE: CA	ZIP CODE:	90221
CAPACITY: 6		CENSUS: 3	DATE:	10/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:00 AM
MET WITH:	House Manager - Martha Miramontes		TIME VISIT/ INSPECTION COMPLETED:	03:20 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 10/19/2024, Community Care Licensing Division (CCLD) staff conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with House Manager, Martha Miramontes. LPA explained the purpose of the visit. This facility is licensed to serve 6 ambulatory adults ages 18 – 59 years. A total of 3 ambulatory clients are currently residing in this facility. The Annual Licensing Fees are current. The facility is a one-story house located in a residential street. The home consists of 3 client bedrooms, 1 staff bedroom, 2 bathrooms, 1 living room are, 1 kitchen, 1 detached garage with a laundry area, and 1 backyard patio area with shaded seating. Outside grounds were toured and no bodies of water were observed. The patio furniture is under a shaded area and accessible to clients. Walkways around the home were clear of hazards. There are no weapons on the premises.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2024

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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Document Has Been Signed on 10/19/2024 03:02 PM - It Cannot Be Edited

Created By: Socorro Leandro On 10/19/2024 at 02:24 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: C-H COMMUNITY LIVING RESIDENTIAL FACILITY	FACILITY NUMBER: 191601267
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80066(a)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: 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 in 1 out of 5 staff files not having a Health Screening Report and Tuberculosis Test Result, which poses a potential health risk to persons in care.
	POC Due Date: 11/12/2024
	Plan of Correction
1 2 3 4	Licensee agrees to email Staff 1's Health Screening Report & Tuberculosis Test Result to Socorro.Leandro@dss.ca.gov. Licensee will work on a plan to maintain current staff records at facility.

Type B

Section Cited

CCR

80075(f)

Health-Related Services

(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross. 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 in 2 out 5 staff records not having a current first aid certificate, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/12/2024
	Plan of Correction
1 2 3 4	Licensee agrees to email Staff 1 & Staff 2's First Aid Certificate to Socorro.Leandro@dss.ca.gov. Licensee will work on a plan to maintain current staff records at facility.

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:

Ulysses Coronel

LICENSING EVALUATOR NAME:

Socorro Leandro

LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2024

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: C-H COMMUNITY LIVING RESIDENTIAL FACILITY	FACILITY NUMBER: 191601267
	VISIT DATE: 10/19/2024

NARRATIVE

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Kitchen area has supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept in locked storage cabinet.

Medications were safe, locked, and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Documents are posted as mandated. Last fire drill was conducted on 09/09/2024. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational. There is a fire extinguisher near the kitchen and it was last served on 02/22/2024. Each client has their own videoconferencing device. There is a landline telephone in the living room.

3 out of 3 client’s bedrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly. Adequate lighting and toiletries accessible to clients. This facility provides clients with hygiene products such as feminine napkins, nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2024

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: C-H COMMUNITY LIVING RESIDENTIAL FACILITY	FACILITY NUMBER: 191601267
	VISIT DATE: 10/19/2024

NARRATIVE

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5 staff records were reviewed, 3 out of 5 staff records had required documentation.

3 client records were reviewed and, 3 out of 3 client records had required documentation.

Deficiencies are being cited based on departments record review in accordance with the California Code of Regulations, Title 22, see LIC809D. Two violations regarding staff records.

An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the House Manager.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2024

LIC809 (FAS) - (06/04)

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