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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191800397
Report Date: 06/19/2023
Date Signed: 06/19/2023 12:18:29 PM

Document Has Been Signed on 06/19/2023 12:18 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:WILLIAMS AND KELLY GROUP HOME #2FACILITY NUMBER:
191800397
ADMINISTRATOR:WILLIAMS, RENEE KELLFACILITY TYPE:
735
ADDRESS:1132 E. 82ND. ST.TELEPHONE:
(323) 582-3700
CITY:LOS ANGELESSTATE: CAZIP CODE:
90001
CAPACITY: 6CENSUS: 5DATE:
06/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Grace Aburtha - DSPTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to Grace Arburtha a Direct Support Professional (DSP) staff member and was granted access into the facility. Administrator Renee Williams arrived shortly thereafter of the facility and was granted access into the home. There are five (5) ambulatory developmentally disabled clients who reside in the home. The facility is vendored through the South Central Los Angeles Regional Center.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention.

Infection Control:

· Infection control practices and Personal Protective Equipment (PPEs) were observed. LPA asked administrator to send a completed infection control plan to LPA within 7 days.


Physical Plant/Environment Safety:

· The facility is a single-story home located in a residential neighborhood that is licensed for a capacity of six (6) ambulatory clients. It consists of four (4) shared client bedrooms, a living room, dining room, a kitchen, one (1) shared client bathroom R#1 which measured at 106.5 Degrees F, and a second private restroom which is connected to the staff room (R#2) measured at 108.6 Degrees F, a front and back patio area, and a detached garage that includes the facility’s washing and drying machines.


· The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors are operational. The facility has ) fully cone (1) charged fire extinguishers that is kept in the dining room area.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2023
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: WILLIAMS AND KELLY GROUP HOME #2
FACILITY NUMBER: 191800397
VISIT DATE: 06/19/2023
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Cleaning supplies and toxic substances are inaccessible to clients in locked storage areas in the garage as well as in a locked closet in the main hallway of the facility.
· Water temperature readings measured between the required 105 - 120 degrees Fahrenheit.
Operational Requirements:
· The Program Design was reviewed.

· Fire clearance was approved by LA County Fire Department for six (6) non-ambulatory developmentally disabled clients.


· Care and supervision to meet the clients’ needs was observed.
Staffing:

· A total of six (6) full-time staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

· Administrator showed LPA that Administrator one of the administrators of the facility Yolanda Minor’s certificate is active and effective through 8/1/2023.


· Five (5) staff files were reviewed for criminal background clearance and training.
· Personnel records have health/TB screenings, CPI training, certifications, and 1st Aid/CPR training.
Client Rights/Information:

· Physician orders were reviewed in client files.

Client Records/Incident Reports:

· Five (5) client files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, nutritional assessments, medication records, and P & I money were reviewed.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: WILLIAMS AND KELLY GROUP HOME #2
FACILITY NUMBER: 191800397
VISIT DATE: 06/19/2023
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 Food Service:

· The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.



· No restricted Health Care plan required for the clients in the facility.

Health Related Services:

· Clients are assisted with self-administration of prescription and non-prescription medications.

· Five (5) centrally stored resident medication records were reviewed. Centrally stored medications are kept in a safe and locked place not accessible to clients in care. Medications are given according to Physician directions.


Incident Medical and Dental:

· All clients have a Needs and Services Plan, and COVID-19 vaccination cards on file.

· Staff training was on file.

Disaster Preparedness, and Emergency Intervention:

· A posted Emergency Disaster Plan LIC 610D containing emergency evacuation information was observed.

· An emergency drill was last documented and 4/21/2023.



Emergency Intervention:

· No manual restraints or seclusion are used with clients in care.



Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies that were cited during the inspection. Exit interview was conducted and report provided.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023
LIC809 (FAS) - (06/04)
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