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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191670135
Report Date: 01/25/2022
Date Signed: 01/25/2022 02:41:28 PM

Document Has Been Signed on 01/25/2022 02:41 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:TAYLOR'S RESIDENTIAL CAREFACILITY NUMBER:
191670135
ADMINISTRATOR:TAYLOR, DELETHAFACILITY TYPE:
735
ADDRESS:1037 EAST GLADWICKTELEPHONE:
(310) 638-8887
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY: 6CENSUS: 5DATE:
01/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:22 PM
MET WITH:Ana Ruth Ortega, Caregiver TIME COMPLETED:
03:00 PM
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On 01/25/2022 at 12:22 pm, Licensing Program Analyst (LPA) Agard conducted an unannounced required annual visit with a primary focus on Infectious Control measures using the new CARE inspection tool. Upon arrival at the facility, LPA Agard conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection. LPA verified that the facility has an approved mitigation plan report.

The facility is licensed to serve six (6) clients with developmental disabilities. Currently, there are five (5) clients present during today’s visit.

LPA met with Caregiver, Ana Ortega and both toured the inside and outside grounds of the facility. LPA was not properly screened for Covid-19 symptoms and temperature was not checked.

During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility’s entrance with visitor’s log. The facility’s designated visitation area is in the front room (living room) of the facility. LPA observed one staff, and clients maintaining 6 feet physical distancing. The staff was observed with a face covering. LPA observed required postings throughout the facility.

All four (4) rooms were inspected. 2 rooms are shared, and 2 rooms are single occupancy. Bed linen were sufficient in amount, mattresses were in good repair, adequate lighting was provided, storage for client personal belongings was observed.

Furniture in the living room observed to be in decent condition. There are security bars on some windows and no weapons on the premises. Both client bathrooms were checked, toilets and water faucets worked properly. The water temperature measured at 139.9 F. A comfortable temperature was maintained in the facility.

LPA toured the kitchen area and observed some supply of perishable and a 7-day of non-perishable food. Cleaning supplies were observed locked. Centrally stored medications were observed stored in their originally received containers and observed locked and inaccessible to clients in care. One fire extinguisher was Cont. 809C

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Troy Agard
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: TAYLOR'S RESIDENTIAL CARE
FACILITY NUMBER: 191670135
VISIT DATE: 01/25/2022
NARRATIVE
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observed in the kitchen area fully charged. Sharps observed locked and inaccessible. Two of the four stove burners were in disrepair.

Outside grounds were toured, no bodies of water were observed. Walkways around the home were clear of hazards. All doorways were free of obstruction.

The following deficiencies were cited during this visit.

1) Hot water temperature 80088

2) Stove in disrepair 80087

An exit interview was conducted, and a copy of this report was provided to caregiver, for Licensee/Administrator.

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Troy Agard
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2022
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Document Has Been Signed on 01/25/2022 02:41 PM - It Cannot Be Edited


Created By: Troy Agard On 01/25/2022 at 01:54 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: TAYLOR'S RESIDENTIAL CARE
FACILITY NUMBER: 191670135

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
80088 Furniture, Fixtures, Equipment, and Supplies(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 (48.8degrees 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. Water temperature measured at 139.9 F. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2022
Plan of Correction
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Licensee/ Administrator will have the water temperature adjusted to be within regulation temperature of 105 -120F and send proof of correction by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Angela J Kendrick
LICENSING EVALUATOR NAME:Troy Agard
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/25/2022 02:41 PM - It Cannot Be Edited


Created By: Troy Agard On 01/25/2022 at 02:06 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: TAYLOR'S RESIDENTIAL CARE
FACILITY NUMBER: 191670135

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087a
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. LPA observed the two back stove burners not to be functioning properly (turning on) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/08/2022
Plan of Correction
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Licensee / Adminstrator will have stove repaired or replaced on or before POC due date and submit proof to LPA via email.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Angela J Kendrick
LICENSING EVALUATOR NAME:Troy Agard
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2022


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