191800897-7-7-2023-28-AS-EZAA-CTHUMX-20230707154304

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191800897
Report Date: 07/07/2023
Date Signed: 07/07/2023 03:43:21 PM

Document Has Been Signed on 07/07/2023 03:43 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:	ANNE SIPPI CLINIC		FACILITY NUMBER:	191800897
ADMINISTRATOR:	OLGA RECENDEZ		FACILITY TYPE:	735
ADDRESS:	2457 ENDICOTT ST.		TELEPHONE:	(323) 221-5177
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90032
CAPACITY:	37	CENSUS: 37	DATE:	07/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:46 PM
MET WITH:	Olga Recendez - Administrator		TIME COMPLETED:	04:05 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 Olga Recendez who is the Administrator of the facility. There are thirty-seven (37) ambulatory developmentally disabled clients who reside in the facility.

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 calendar days.

Physical Plant/Environment Safety:

· The facility is a single-story building located in a residential neighborhood that is licensed for ambulatory clients. It consists of nineteen (19) shared client bedrooms, dining room, a kitchen, an activity room, four (4) shower rooms for the clients, a front entrance area as well as a back lot area which includes an extensive garden and parking lot, a medications room, a main front office, 4 (four) individual staff office, a staff break room, 3 staff restrooms, and a separate laundry room. Clients have their own client bathrooms, and the hot water temperature in Client Restroom #1, located in Room 5 measured at 114.6 Degrees F, Restroom #2, located in Room #9, measured at 108.8 Degrees F, Restroom #3, located in Room #13, measured at 106.7 Degrees F, Restroom #4, located in Room #15, measured at 108.7 Degrees F, Restroom #5, located in Room #14, measured at 109.9 Degrees F, and Restroom #6, located in Room #6 of the facility, measured at 115.2 Degrees F.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ANNE SIPPI CLINIC	FACILITY NUMBER: 191800897
	VISIT DATE: 07/07/2023

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· 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 and the fire alarm in the facility are operational. The facility has five (5) charged fire extinguishers that is kept in the hallways, the kitchen, laundry room area. Cleaning supplies and toxic substances are inaccessible to clients in locked storage areas in the stockroom 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 thirty-seven (37) ambulatory developmentally disabled clients.

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

· A total of twenty-three (23) full-time staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

· Administrator's certificate is valid and effective through 11/10/2023.

· 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.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ANNE SIPPI CLINIC	FACILITY NUMBER: 191800897
	VISIT DATE: 07/07/2023

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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.

LPA was not able to complete the annual inspection and will be returning at a later date in order to do so

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023

LIC809 (FAS) - (06/04)

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