<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191640255
Report Date: 05/26/2023
Date Signed: 05/26/2023 03:21:22 PM

Document Has Been Signed on 05/26/2023 03:21 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 HOMEFACILITY NUMBER:
191640255
ADMINISTRATOR:EDWARD GOODSONFACILITY TYPE:
735
ADDRESS:1911 W. 137TH STREETTELEPHONE:
(310) 632-1213
CITY:COMPTONSTATE: CAZIP CODE:
90222
CAPACITY: 16CENSUS: DATE:
05/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:57 PM
MET WITH:Edward Goodson-AdministratorTIME COMPLETED:
03:20 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
On 5/26/2023, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Edward Goodson/Administrator and the purpose of today’s visit was explained. The facility is licensed to operate for (16) ambulatory only (developmentally disabled or Mentally Ill) adults ages 18 through 59. Currently, the home has (16) clients. None the clients have Restricted Health Care Conditions, and none are utilizing postural supports or protective devices.

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 conducted a records review of (4) client records, (4) staff records, (4) clients Personal & Incidental Records and reviewed the facility disaster plan. All client & Staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (4) Client Medication Administration Records.

LPA and Administrator toured the inside and outside of the facility. All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting was observed, plenty of dresser and closet space was observed. Walls and floors were clean and 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 regulation. Toilets and water faucets worked properly. Shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature properly measured between 105°-120°F Kitchen 108.6°F, Bathroom #102.3°F & Bathroom #2 103.4°F.

Evaluation Report continues LIC 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2023
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 5
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: 05/26/2023
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
Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide detector was observed and operational. Smoke detectors were working properly, fire extinguishers were fully charged, toxins and knifes were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Outside grounds were toured and no bodies of water were observed. Exits/ Walkways around the home were free of debris and hazards.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8.

See D pages for Citations and LIC 811 for details.


An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to the Administrator/ Edward Goodson.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 05/26/2023 03:21 PM - It Cannot Be Edited


Created By: Alfonso Iniguez On 05/26/2023 at 03:03 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: 05/26/2023

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 the licensee did not comply with the section cited above in keeping the faclity in ggod repair which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/09/2023
Plan of Correction
1
2
3
4
Licensee will ensure to repalce broken blinds in client's room
Type B
Section Cited
CCR
85088(c)(2)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (2) Bedroom furniture including, in addition to (c)(1) above, for each client, a chair, a night stand, and a lamp or lights necessary for reading.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation the licensee did not comply with the section cited above in no providing extra chair and nightstand for client in a shared bedroom which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/09/2023
Plan of Correction
1
2
3
4
Licensee will ensure to provide extra chair and night stand in client's bedroom.
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:Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2023


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 05/26/2023 03:21 PM - It Cannot Be Edited


Created By: Alfonso Iniguez On 05/26/2023 at 03:03 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: 05/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review the licensee did not comply with the section cited above in keeping a TB test in staff record which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/09/2023
Plan of Correction
1
2
3
4
Licensee will ensure to provide TB test for staff and file it in staff record
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review the licensee did not comply with the section cited above in having expired first aid certificates for staff members which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/09/2023
Plan of Correction
1
2
3
4
Licensee will ensure staff will renew 1st AID certificate and keep a copy of their certificates in their files.
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:Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/26/2023 03:21 PM - It Cannot Be Edited


Created By: Alfonso Iniguez On 05/26/2023 at 03:03 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: 05/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)(5)
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review the licensee did not comply with the section cited above in logging the into the MAR correctly which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/09/2023
Plan of Correction
1
2
3
4
Licensee will ensure to re-train staff on how to log in every day in MAR
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5