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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191670135
Report Date: 01/18/2024
Date Signed: 01/18/2024 03:01:05 PM

Document Has Been Signed on 01/18/2024 03:01 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
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: 4DATE:
01/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:22 AM
MET WITH:Ana Ortega caregiverTIME COMPLETED:
03:30 PM
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On 01/18/2024 at 11:22 am Licensing Program Analyst (LPA) David España conducted an unannounced Required-1-year annual visit. Upon arrival at the facility, LPA España conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection (No COVID-19 cases). LPA verified that the facility has an approved mitigation plan report. LPA was granted access and allowed to enter the facility to conduct the inspection.

LPA was met by Ana Ortega caregiver and later Assistant Administrator Johnathon Taylor.The Adult Residential Facilities (ARF) facility is licensed to serve six (6) clients with developmental disabilities. Currently, the facility has four (4) clients, none were present during today’s visit. The facilities annual fees are current. As part of the inspection, my primary focus was on infection control. LPA observed the facility’s infection control practices: LPA observed a sanitizing station at the facility entrance, where my temperature was taken. PPE supplies are readily available to staff and residents, and additional supplies are stored. Sufficient paper, cleaning, and disinfecting supplies were also observed. The facility has the mandated COVID infection control posters.

LPA and Ana Ortega, caregiver, toured the facility. All four (4) rooms were inspected. 2 rooms are shared, and 2 rooms are single occupancy. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. LPA further observed the facility to be clean and appropriately furnished at the time of visit. Bathrooms were observed to be clean and operational. LPA observed that the fire extinguisher was fully charged and there were no bodies of water on the premises. All windows and window screens were in good condition. The water temperature was within guidelines and measured 117 degrees F. Smoke/Carbon monoxide detectors were operable.

Continued on LIC-809

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2024
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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: TAYLOR'S RESIDENTIAL CARE
FACILITY NUMBER: 191670135
VISIT DATE: 01/18/2024
NARRATIVE
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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. A comfortable temperature was maintained in the facility. The kitchen area was checked and in compliance with title 22. Perishable and non-perishables food supply was adequate at time of visit. All disinfectants, toxins, knives, staff/resident files, and cleaning solutions were locked and inaccessible to residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).
LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing (www.cdss.ca.gov) for Provider Informational Notices (PIN) and for any updates relating to COVID-19 guidance.

During today’s visit there was one (1) deficiency cited, Title 22, Division 6 Chapter 6 Article 06. Continuing Requirements 85066(a-c) Personnel Records. There was one technical assistant note issued today's visit Disaster Preparedness - Technical Assistance: 1565(a).

An exit interview was conducted, and a copy of the facility evaluation report was provided to Ana Ortega caregiver

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
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Document Has Been Signed on 01/18/2024 03:01 PM - It Cannot Be Edited


Created By: David Espana On 01/18/2024 at 02:46 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: TAYLOR'S RESIDENTIAL CARE
FACILITY NUMBER: 191670135

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85066

(a)In addition to Section 80066, the following shall apply. (b) A dated employee time schedule shall be developed at least monthly, shall be displayed conveniently for employee reference and shall contain the following information for each employee: (1) Name. (2) Job title. (3) Hours of work. (4) Days off. (c) The licensee shall maintain documentation that the administrator has met the certification requirements specified in Section 85064.2.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above. LPA did not review or observe LIC503; LIC508; LIC9052 for Staff #2 and #3 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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Administrator/licensee shall have reviewed LIC 311 provided at today's visit and have all LIC forms submitted to LPA by POC date david.espana@dss.ca.gov.
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:Ulysses Coronel
LICENSING EVALUATOR NAME:David Espana
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2024


LIC809 (FAS) - (06/04)
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