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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191640255
Report Date: 06/15/2024
Date Signed: 06/15/2024 03:54:11 PM

Document Has Been Signed on 06/15/2024 03:54 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:FRANK'S ADULT RESIDENTIAL HOMEFACILITY NUMBER:
191640255
ADMINISTRATOR/
DIRECTOR:		EDWARD GOODSONFACILITY TYPE:
735
ADDRESS:1911 W. 137TH STREETTELEPHONE:
(310) 632-1213
CITY:COMPTONSTATE: CAZIP CODE:
90222
CAPACITY: 16CENSUS: DATE:
06/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Administrator - Edward GoodsonTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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On 6/15/2024, Licensing Program Analyst (LPA) Leandro conducted an unannounced annual required visit. LPA met with a staff and the purpose of today’s visit was explained. The facility is licensed to operate for (16) ambulatory adults ages 18 through 59. Currently, the home has (15) clients.

The facility is a two-story structure located in a residential neighborhood. It consists of the following: 10 bedrooms, 3 bathrooms, 1 kitchen with 2 dining areas, laundry is located outside, office areas located in the front, and outside area with shaded seating.

LPA reviewed 5 staff records and 5 client records. Staff and client records had missing required documents.

LPA and staff toured the inside and outside of the facility. All client rooms were checked. The back bedrooms smelled like cigarette smoke and were not clean. Plenty of dresser and closet space was observed. Bathroom #2 faucet was in disrepair. The hot water temperature measured 139.6 F.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2024
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 18
Document Has Been Signed on 07/03/2024 04:41 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 07/03/2024 04:39 PM


Created By: Socorro Leandro On 06/15/2024 at 02:50 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
EL SEGUNDO ASC, 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: 06/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)(1)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022.  (1) The Infection Control Plan shall include all of the following: 

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 not having an Infection Control Plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2024
Plan of Correction
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Licensee will create an Infection Control Plan and email it to Socorro.Leandro@dss.ca.gov.
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
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Based on observation, the licensee did not comply with the section cited above in having bedrooms that smell like cigarette smoke, a broken faucet in bathroom #2, bedrooms not being clean and sanitary, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2024
Plan of Correction
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Licensee will fix faucet in bathroom#2, and clean and sanitize bedrooms. Licensee will create a plan to ensure that facility is clean, safe, sanitiry, and in good repair at all times. Licensee will email proof of correction Socorro.Leandro@dss.ca.gov.
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: 06/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2024


LIC809 (FAS) - (06/04)
Page: 2 of 18
Document Has Been Signed on 07/03/2024 04:42 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 07/03/2024 04:41 PM


Created By: Socorro Leandro On 06/15/2024 at 02:50 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
EL SEGUNDO ASC, 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: 06/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having RAID bottles accessible to clients in care which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2024
Plan of Correction
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Licensee will create a plan to ensure that poisons are inaccessible to clients in care.
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in hot water temperature measuring 139.6 Fahrenheit degrees which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2024
Plan of Correction
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Licensee will fix hot water temperature to 105 to 120 dgrees Fahrenheit. Licensee will email proof of correction to Socorro.Leandro@dss.ca.gov.
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: 06/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2024


LIC809 (FAS) - (06/04)
Page: 4 of 18
Document Has Been Signed on 07/03/2024 04:44 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 07/03/2024 04:43 PM


Created By: Socorro Leandro On 06/15/2024 at 02:50 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
EL SEGUNDO ASC, 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: 06/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80020(c)
Fire Clearance
(c) A licensee of an Adult Residential Facility or Group Home utilizing secured perimeters shall conduct fire and earthquake drills pursuant to Health and Safety Code section 1531.15(h).

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 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2024
Plan of Correction
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Licensee will create a plan to ensure compliance with CCR80020(c) and email proof of correction to Socorro.Leandro@dss.ca.gov.
Type B
Section Cited
CCR
80066(a)
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:

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 5 out 5 records having missing required documentation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2024
Plan of Correction
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Licensee will create a plan to ensure that each personnel is record is complete and in compliance. Licensee will complete R1 to R5 records. Licensee will email proof of correction to Socorro.Leandro@dss.ca.gov.
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: 06/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2024


LIC809 (FAS) - (06/04)
Page: 6 of 18
Document Has Been Signed on 07/03/2024 04:45 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 07/03/2024 04:44 PM


Created By: Socorro Leandro On 06/15/2024 at 02:50 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
EL SEGUNDO ASC, 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: 06/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85065(e)(2)
Personnel Requirements
(2) In facilities with a licensed capacity of 16 or more clients an employee shall be designated to have primary responsibility for food planning, preparation and service.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in not having a designated staff to be responsible for food planning, preparation, and service, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2024
Plan of Correction
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Licensee will create a plan to ensure that there is a designated staff member with fodd planning, preparation and service. Licensee will email proof of correction to Socorro.Leandro@dss.ca.gov.
Type B
Section Cited
CCR
80070(a)
Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

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 5 out of 5 client records having missing required documentation, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2024
Plan of Correction
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Licensee will complete records for Client 1 to Client 5. Licensee will create a plan to ensure complaiance with client records and email proof of correction to Socorro.Leandro@dss.ca.gov.
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: 06/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2024


LIC809 (FAS) - (06/04)
Page: 8 of 18
Document Has Been Signed on 07/03/2024 04:46 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 07/03/2024 04:45 PM


Created By: Socorro Leandro On 06/15/2024 at 02:50 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
EL SEGUNDO ASC, 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: 06/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

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 5 out 5 client records not having their Medication Administration Record filled out which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2024
Plan of Correction
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Licensee will re-train staff on how to document MAR records and create a plan to stay in compliance. Licensee will email proof of correction to Socorro.Leandro@dss.ca.gov.
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

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 not having an emergency and plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2024
Plan of Correction
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Licensee will create an an emergency and plan and email it to Socorro.Leandro@dss.ca.gov.
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: 06/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2024


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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: FRANK'S ADULT RESIDENTIAL HOME
FACILITY NUMBER: 191640255
VISIT DATE: 06/15/2024
NARRATIVE
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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, 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.

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to the Administrator.

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

DATE: 06/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2024
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