191601377-2-28-2023-11-AS-PBUR-CPH67E-20230228193326

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191601377
Report Date: 02/03/2023
Date Signed: 02/28/2023 07:33:47 PM

Document Has Been Signed on 02/28/2023 07:33 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:	EXCELSIOR HOUSE		FACILITY NUMBER:	191601377
ADMINISTRATOR:	JAVANFARD, ELAN		FACILITY TYPE:	772
ADDRESS:	1007 SOUTH MYRTLE AVENUE		TELEPHONE:	(310) 412-4191
CITY:	INGLEWOOD	STATE: CA	ZIP CODE:	90301
CAPACITY: 14		CENSUS: 7	DATE:	02/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Shelly Mayers		TIME COMPLETED:	03:45 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	Licensing Program Analysts (LPAs) Pamela Bunker conducted an unannounced required 1-year visit with the primary focus on Infection Control measures and using the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPAs were properly screened for COVID-19 symptoms and their temperature was checked. LPA Bunker met with the Lead Clinical Supervisor Shelly Mayers. LPA Bunker explained the purpose of today's Annual Inspection. LPA Bunker verified that the facility has an approved mitigation plan report. The facility's annual fees are current. The facility currently has (9) ambulatory clients in placement. The following Domain will be observed and reviewed: Infection Control Practices "I will be using this tool and methods that have been developed to improve the efficiency and accuracy of the Department of Social Services' facility inspections." The facility is a two-story building located in a business/residential neighborhood. Lead Clinical Supervisor Ms. Mayers and LPA Bunker made a complete tour of the facility which consisted of upstairs and downstairs. The downstairs consists of the main office, living room/common area, dining room/group meeting area, kitchen, Administrator's office, Counselor's office, Therapist's office, medication room, arts, and craft closet, two (2) all-gender bathrooms, utility closet emergency supplies room, and numerous of storage closets are downstairs. The upstairs has seven (7) bedrooms, two (2) all-gender bathrooms, one (1) all-gender staff restroom, laundry room, staff lounge, Doctor's office, Director's office, and numerous storage closets. The outside includes a gated front parking lot, a backyard-covered patio/shaded areas, and indoor/outdoor activity areas. See LIC9099-C page 2

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023

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

Document Has Been Signed on 02/28/2023 07:33 PM - It Cannot Be Edited

Created By: Pamela Bunker On 02/03/2023 at 02:30 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: EXCELSIOR HOUSE	FACILITY NUMBER: 191601377
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited


	Deficient Practice Statement
1 2 3 4	87303 (e) (2) Maintenance and Operation: Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degrees F (41 degrees C) and not more than 120 degrees F (49 degrees C). Hot water temperature in the resident's bathroom tested at 146.4. Poses in immediate health, safety, or personal rights risk to the person in care.
	POC Due Date: 02/04/2023
	Plan of Correction
1 2 3 4	Licensee must adjust the hot water temperature to automatically regulate temperature to an attained temperature of not less than 105 degrees F (41 degrees C) and not more than 120 degrees F (49 degrees C).

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:

Stephanie Cifuentes

LICENSING EVALUATOR NAME:

Pamela Bunker

LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023

LIC809 (FAS) - (06/04)

Page: 2 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: EXCELSIOR HOUSE	FACILITY NUMBER: 191601377
	VISIT DATE: 02/03/2023

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

Continued LIC809-C page #2

Documents were posted as mandated throughout the facility, on the walls in the office and hallways.
The following Title 22 regulated areas were audited and found to be in compliance: Bedrooms contain the required furniture. The client’s bedrooms were inspected for safety, privacy, and comfort. The living areas are clean, bathrooms are clean and operational. The first aid kit is fully stocked with a manual, a working telephone, smoke, and carbon monoxide detectors were in compliance, fire extinguishers are fully charged, medications were centrally stored and properly locked in the medication room, no firearms on the premises, the client's bedroom windows have no sliding window lock with thumbscrews, all exit doors were in compliance, covered trash cans, and no bodies of water were present. Hazardous items are inaccessible to clients, the yard is free of debris and hazards.

Based on LPA’s observations, interviews that were conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 1 are being cited on the attached LIC9099-D.

Appeal rights were discussed, and copies of the Facility Evaluation Reports, LIC809, LIC809-C, and D were provided to Lead Clinical Supervisor Ms. Mayers

Staff states staff was given training on dependent adult and elder abuse reporting.

An exit interview was conducted.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3