191605185-2-17-2023-11-AS-DESA-CP5RVN-20230217122150

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191605185
Report Date: 02/17/2023
Date Signed: 02/17/2023 12:22:05 PM

Document Has Been Signed on 02/17/2023 12:22 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:	WITHERS ADULT RESIDENTIAL FACILITY		FACILITY NUMBER:	191605185
ADMINISTRATOR:	JACQUELINE SPENCER		FACILITY TYPE:	735
ADDRESS:	1210 SOUTH CLIVEDEN AVENUE		TELEPHONE:	(310) 639-2523
CITY:	COMPTON	STATE: CA	ZIP CODE:	90220
CAPACITY: 8		CENSUS: 4	DATE:	02/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:56 AM
MET WITH:	Jacqueline Spencer		TIME COMPLETED:	12:35 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 Analyst (LPA) David España conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA España was met by Mrs. Jacqueline Spencer; Administrator and the purpose of today’s visit was explained. The facility Withers Adult Residential Facility is licensed to serve 8 developmentally disabled clients (age 18-64; 1-17; 65+) There are currently 4 clients from South Central Regional Center in placement. All (4) clients are ambulatory. The facility is a single-story structure located in a residential neighborhood. It consists of the following: 5 bedrooms, 3 bathrooms (Denote: restroom #1 is considered for staff per Mrs. Jacqueline Spencer), family room/dining room, kitchen, living room, with no shaded area, indoor and outdoor activity area, laundry room and an attached garage. LPA España and staff (Mrs. Jacqueline Spencer) toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds (total of ten beds at the facility) 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 restroom #3 at 119.1 F; restroom #2 at 120.0 F; and restroom #1 at 117.F (i.e., staff restroom is numbered 1). A comfortable temperature is maintained in the facility. LPA España 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 an enough perishable and non-perishable food available which is stored properly. Fire extinguishers (total of three fire extinguishers: 2 located in kitchen, and 1 located by room number 5) were charged, 10 smoke detectors (in each bedroom) and 2 Carbon Monoxide (in hallways) were operable.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023

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: WITHERS ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 191605185
	VISIT DATE: 02/17/2023

NARRATIVE

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During the visit, LPA España observed the facility infection control practices. LPA España observed screening protocols for visitors, staff and residents, sanitizing stations (Located in common areas and restrooms). LPA España observed staff and residents were wearing face coverings, an isolation room and required postings throughout the facility. LPA España observed the facility has a 30-day supply of Personal Protective Equipment (PPEs).

LPA España advised the Mrs. Spencer (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.

Exit interview held. A copy of the report was provided to Mrs. Jacqueline Spencer, Administrator.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/17/2023 12:22 PM - It Cannot Be Edited

Created By: David Espana On 02/17/2023 at 11:43 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: WITHERS ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 191605185
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(g)

This requirement is not met as evidenced by: Building and Grounds--(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stoned where inaccessible to clients.
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in as LPA España conducted initial walk through at the facility and noted toxins, namely, WindFresh, dish washing soap on chair in the garage area by door entrance (poses a danger to clients due to accessibility). Additionally, the backyard has two iron doors (poses a danger to clients due to accessibility) by fireplace wall, coupled with, two pipes on the ground that are accessible to clients/residents which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/24/2023
	Plan of Correction
1 2 3 4	Long term plan of correction is to have a service plan in enacted and followed by all staff members and a detailed written plan of correction is to be sent via email to David.espana@dss.ca.gov.

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:

Ulysses Coronel

LICENSING EVALUATOR NAME:

David Espana

LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023

LIC809 (FAS) - (06/04)

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