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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191601607
Report Date: 06/22/2024
Date Signed: 06/22/2024 01:35:01 PM

Document Has Been Signed on 06/22/2024 01:35 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:SENASAC HOUSEFACILITY NUMBER:
191601607
ADMINISTRATOR/
DIRECTOR:		LATASHIA HAMMONDFACILITY TYPE:
735
ADDRESS:3748 SENASACTELEPHONE:
(562) 421-3889
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY: 6CENSUS: 4DATE:
06/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH: Administrator - Latashia HammondTIME VISIT/
INSPECTION COMPLETED:
01:40 PM
NARRATIVE
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On 06/22/2024 at around 9:50 AM, Licensing Program Analyst (LPA) Leandro conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with the Administrator Latashia Hammond. LPA explained the purpose of the visit and was accompanied by a staff inside and outside the facility during this inspection.

This facility is licensed to serve 4 adults ages 18 – 59 years.

A total of 4 ambulatory clients are currently residing in this facility.

The facility is a one-story house located in a residential street. The home consists of 4 client bedrooms, 2 bathrooms, 1 living room, 1 dining room, 1 kitchen, 1 detached garage, 1 office space, 1 laundry space 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 security bars or weapons on the premises.

LPA toured the kitchen area and observed 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.

LPA observed that 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 earthquake and fire drill was conducted on 5/1/2024. First aid kit is fully stocked. Smoke and carbon monoxide detectors were in compliance and operational. There are fire extinguishers in the facility and they were last serviced on 3/1/2024.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2024
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 06/22/2024 01:35 PM - It Cannot Be Edited


Created By: Socorro Leandro On 06/22/2024 at 01:12 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: SENASAC HOUSE
FACILITY NUMBER: 191601607

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80091(a)
Prohibited Health Conditions
(a) In adult CCFs clients who require health services or have a health condition including, but not limited to, those specified below shall not be admitted or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 4 clients who has been diagnoised with a prohibited health condition since 4/6/2023, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/16/2024
Plan of Correction
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Licensee will submit the Dementia Waiver Request (follow guidelines from emai) and email it to Ernand.Dabuet@dss.ca.gov and CC Socorro.Leandro@dss.ca.gov.
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:Ulysses Coronel
LICENSING EVALUATOR NAME:Socorro Leandro
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2024


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: SENASAC HOUSE
FACILITY NUMBER: 191601607
VISIT DATE: 06/22/2024
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4 out of 4 clients’ 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. LPA tested hot water temperature and it measured between 105 and 120 degrees Fahrenheit. This facility provides clients with hygiene products such as nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb.

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

4 client records were reviewed and, 4 out of 4 client records had required documentation. There is one client who was diagnosed with a prohibited health condition.

Deficiencies are being cited based on record review in accordance with the California Code of Regulations, Title 22, see LIC809D. A violation regarding prohibited health condition.

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 Administrator.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2024
LIC809 (FAS) - (06/04)
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