191640255-10-17-2022-11-AS-MBRN-CKART8-20221017131756

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191640255
Report Date: 10/14/2022
Date Signed: 10/17/2022 01:18:08 PM

Document Has Been Signed on 10/17/2022 01:18 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:	FRANK'S ADULT RESIDENTIAL HOME		FACILITY NUMBER:	191640255
ADMINISTRATOR:	EDWARD GOODSON		FACILITY TYPE:	735
ADDRESS:	1911 W. 137TH STREET		TELEPHONE:	(310) 632-1213
CITY:	COMPTON	STATE: CA	ZIP CODE:	90222
CAPACITY: 16		CENSUS: 16	DATE:	10/14/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Edward Goodson		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 Analyst (LPA Martessa Brown conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA conducted risk assessment before entering the building and there is no Covid-19 Cases. LPA was met by Edward Goodson the licensee and the purpose of today’s visit was explained. The facility is licensed to serve 16 Ambulatory Only, Adults Ages 18-59 Years. There are currently 16 clients in placement. All 16 clients are ambulatory. The facility is a two-story structure located in a residential neighborhood. It consists of the following: 10 bedrooms, three bathrooms, living room, kitchen with 2 dining areas and TV room, laundry is located outside, office areas located in the front, outside covered area with table and chairs. LPA and Administrator toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, 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 118 F. A comfortable temperature is maintained in the facility. LPA 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 enough perishable and non-perishable food available which is stored properly. Fire extinguisher was charged, smoke detectors and Carbon Monoxide were operable. LIC 809-C is on the next page.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022

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 10/17/2022 01:18 PM - It Cannot Be Edited

Created By: Martessa Brown On 10/14/2022 at 02:42 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: FRANK'S ADULT RESIDENTIAL HOME	FACILITY NUMBER: 191640255
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation), LPA observed 2 out of 10 overhead lights in clients rooms were not working. LPA observed bathroom #2's was halfway painted and the hot water was not working. Bath bathroom #3 shower was not in operation. the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/21/2022
	Plan of Correction
1 2 3 4	Licensee will repair the lights in the clients room. LIcensee is to come up with a plan on when Bathrooms #2 and #3 will be repair and email to LPA Brown by POC due date 10/21/22

Type B

Section Cited

CCR

80075(b)(5)(C)

Health-Related Services

(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (C) A record of each dose is maintained in the client's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the client's response. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in 4 out of 16 clients medication records were missing initial of when am medication was taking on 10/11/22 and 10/14/22 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/21/2022
	Plan of Correction
1 2 3 4	Licensee will train staff to update medication records and come up with a plan how he will insure medication books is updated by 10/21/22.

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:

Eva M Alvarez

LICENSING EVALUATOR NAME:

Martessa Brown

LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022

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: FRANK'S ADULT RESIDENTIAL HOME	FACILITY NUMBER: 191640255
	VISIT DATE: 10/14/2022

NARRATIVE

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There were deficiencies observed and Title 22 Regulations are being cited, please see LID809D.

During today’s visit LPA observed that the overhead lighting in 2 out of 10 bedrooms were in disrepair.

During today’s visit LPA observed Bathroom #2 sink hot water was not working.

During today’s visit LPA observed Bathroom #3 shower was not in operation.

During todays visit LPA observed medication book for clients was not updated and missing staff initials.

LPA also informed of Annual Fee past due and Administrator stated will pay on 11/7/22.

Exit interview held A copy of the report and appeal rights were provided to Edward Goodson the licensee.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022

LIC809 (FAS) - (06/04)

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