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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191601667
Report Date: 07/28/2023
Date Signed: 07/31/2023 03:01:33 PM

Document Has Been Signed on 07/31/2023 03:01 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:C. C'S RESIDENTIAL FACILITY FOR ADULTSFACILITY NUMBER:
191601667
ADMINISTRATOR:BEVERLY BRINSONFACILITY TYPE:
735
ADDRESS:11101 DOTY AVENUETELEPHONE:
(310) 560-7975
CITY:INGLEWOODSTATE: CAZIP CODE:
90303
CAPACITY: 6CENSUS: 6DATE:
07/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Beverly BrinsonTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced Required - 1 Year Annual visit. The primary focus is on Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA Bunker called Licensee Beverly Brinson and conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA verified that the facility has an approved Mitigation Plan Report. LPA was properly screened for COVID-19 symptoms and temperature was checked. LPA observed a sanitizing station at the facility entrance; visitors log with COVID-19 screening and temperature log, and records of daily COVID-19 screening and temperature checks of residents and staff. PPE supplies are readily available to staff, and an additional 30-day supply of PPE is stored in the storage room; sufficient paper, cleaning, and disinfecting supplies were observed. LPA reviewed the facility’s surveillance testing records. Staff and residents are fully vaccinated. The facility's annual fees are current.

The following 12 Domain will be observed and reviewed: Infection Control, Physical Plant & Environmental, Operational Requirements, Staffing, Personnel Records-Training, Client Rights-Information, Client Rights-Information, Client Records-Incident Reports, Food Service, Health-Related Services, Incidental Medical Services, Disaster Preparedness, and Emergency Intervention. "LPA Bunker 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 single-story corner home located in a residential neighborhood. Licensee Ms. Brinson and LPA Bunker toured the entire facility inside and out which consisted of the following: Living room, dining room, kitchen, 4 bedrooms, 2 bathrooms, office, laundry room, attached garage, shaded area, indoor/outdoor activity areas. Bedrooms #1-4 are designated as resident's bedrooms.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2023
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: C. C'S RESIDENTIAL FACILITY FOR ADULTS
FACILITY NUMBER: 191601667
VISIT DATE: 07/28/2023
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Continued LIC809-C page

Documents were posted as mandated. The following Title 22 regulated areas were audited and found to be in compliance: Bedrooms contain the required furniture. The resident'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, hot water temperature of 110 degrees Fahrenheit, working telephone, smoke and carbon monoxide detectors were in compliance, fire extinguishers are fully charged, medications were centrally stored and properly locked in the office cabinet and records are current, ample supply of perishable and nonperishable food, adequate linen supply, fire/emergency drill conducted on 02/13/2023. No firearms on the premises, the client's bedroom windows have no sliding window locks 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. Ms. Brinson states staff was given training on dependent adult and elder abuse reporting.
Due to time, constraint LPA Bunker will return at a later date.

There were no deficiencies cited. LPA Bunker provided Ms. Brinson with copies of the Facility Evaluation Reports.

An exit interview was conducted.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023
LIC809 (FAS) - (06/04)
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