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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
191840975
Report Date:
12/10/2021
Date Signed:
11/14/2022 08:39:50 AM
Document Has Been Signed on
11/14/2022 08:39 AM
- 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:
COMEAUX FAMILY HOME
FACILITY NUMBER:
191840975
ADMINISTRATOR:
RUFFINS, PECOLA
FACILITY TYPE:
735
ADDRESS:
1470 W. ADAMS BLVD.
TELEPHONE:
(323) 732-2424
CITY:
LOS ANGELES
STATE:
CA
ZIP CODE:
90007
CAPACITY:
15
CENSUS:
9
DATE:
12/10/2021
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
11:57 AM
MET WITH:
RUFFINS, PECOLA Administrator
TIME COMPLETED:
05:57 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted an annual/required visit at 11:57am. LPA met with Administrator Stella Ruffins and explained the reason for the visit. Some of the clients receive services from the South Central Regional Center. The home is licensed to serve up to (15) fifteen clients ages 18 - 59. There are currently (9) nine clients in facility. Administrator Stella Ruffins has a current Administrator Certificate (6010621735) with expiration date of 02/20/22.
At 12:12am LPA and Administrator conducted a tour of the two story home. The home consists of (10) ten bedrooms (7) client bedrooms & (2) two staff bedrooms], (6) bathrooms, living room, dining area, kitchen, indoor/outdoor activity areas, attic and basement. The front and backyard are not well maintained. There are no pools or large bodies of water. There is a shaded seating area for the clients located in the backyard. This shaded area has broken support beam that Administrator stated she can have repaired in a month. Passageways and exits are free of obstruction. There is sufficient lighting throughout the home. The water temperature was tested in multiple bathrooms on the first and second floors of the home and temperature measured between 114.4F - 128.4F which is not within the required 105 - 120 degrees. At 12:54PM LPA and Administrator observed the hot water temperature in the bathroom adjacent to room #9 to measure 125.6F and at 1:02 pm LPA and administrator observed hot water temperature in the restroom adjacent to room 7' at 128.4 The Clients bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have sufficient closet space. Clients beds have the required linen and the linen is in good condition. Each bedroom has a smoke detector and detectors were tested and operable during the visit. Multiple carbon monoxide detectors were observed throughout the home. There are multiple fire extinguishers located throughout the home. Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked in a kitchen cabinet and are inaccessible to clients. Cleaning solutions are also locked and inaccessible to clients. There is sufficient perishable and non-perishable foods located in multiple refrigerators. The food is also stored properly. The medications are centrally stored in the kitchen and are being administered as prescribed . Facility is operating within the approved capacity.
SUPERVISORS NAME
:
Christine Yee
LICENSING EVALUATOR NAME
:
Alberto Lopez
LICENSING EVALUATOR SIGNATURE
:
DATE:
12/10/2021
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/10/2021
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
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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 CNTR DR. ST 500
MONTEREY PARK
,
CA
91754
FACILITY NAME:
COMEAUX FAMILY HOME
FACILITY NUMBER:
191840975
VISIT DATE:
12/10/2021
NARRATIVE
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The fire extinguishers were observed to be fully charged and in compliance.
The following deficiencies were observed during today's visit;
The hot water temperature in the bathrooms listed below were not in compliance with Title 22 Regulations: At 12:54am, Bathroom adjacent to Room 9 - measured at 125.6 degrees F & bathroom adjacent to room number 11 - measured at 128.4 degrees F
At 12:15 pm Jay Murphy Ruffins, maintenance man, accompanied LPA with the tour of the remainder of the outside of the home. At 12:19pm LPA and Mr Murphy observed the 2 window screen on the back of the home in disrepair.
At 12:16 LPA and Jay Murphy observed the outside shaded area with a broken support beam and in need of repair. At 1:02 pm LPA brought up the broken support beam to the attention of the Administrator and was observed by LPA and administrator.
One person, not resident or staff P1 has been residing at the home since August 1, 2021 according to Administrator and LPA verified that she is not cleared or associated to facility. Civil Penalties issued.
The following deficiencies were observed to be in violation of California code of Regulations, Title 22, Division 6 (refer to 809D)
An exit interview was conducted, and a copy of this report was provided along with the Appeals Rights.
SUPERVISORS NAME
:
Christine Yee
LICENSING EVALUATOR NAME
:
Alberto Lopez
LICENSING EVALUATOR SIGNATURE
:
DATE:
12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/10/2021
LIC809
(FAS) - (06/04)
Page:
8
of
9
Document Has Been Signed on
11/14/2022 08:39 AM
- It Cannot Be Edited
Created By:
Alberto Lopez
On
12/10/2021
at
03:30 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 CNTR DR. ST 500
MONTEREY PARK
,
CA
91754
FACILITY NAME:
COMEAUX FAMILY HOME
FACILITY NUMBER:
191840975
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
12/10/2021
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
This requirement is not met as evidenced by: LPA and administrator observed water temperture in bathroom adjecent to room #9 at 125.6 degrees F and the temperture in bathroom adjecent to room #7 at 128.4
Deficient Practice Statement
1
2
3
4
The hot water temperature in the bathrooms listed below were not in compliance with Title 22 Regulations: At 12:54am, Bathroom adjacent to Room 9 - measured at 125.6 degrees F & bathroom adjacent to room number 11 - measured at 128.4 degrees F.
POC Due Date:
12/11/2021
Plan of Correction
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2
3
4
Administrator will adjust the temperture of the 2 bathrooms and provide evidence by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
12/10/2021
Plan of Correction
1
2
3
4
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:
Christine Yee
LICENSING EVALUATOR NAME:
Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE:
12/10/2021
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/10/2021
LIC809
(FAS) - (06/04)
Page:
4
of
9
Document Has Been Signed on
11/14/2022 08:39 AM
- It Cannot Be Edited
Created By:
Alberto Lopez
On
12/10/2021
at
04:39 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 CNTR DR. ST 500
MONTEREY PARK
,
CA
91754
FACILITY NAME:
COMEAUX FAMILY HOME
FACILITY NUMBER:
191840975
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
12/10/2021
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(d)
Criminal Record Clearance
(d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation P1 was reciding in facility without background clearace and associated to facility.
POC Due Date:
12/10/2021
Plan of Correction
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2
3
4
P1 Must be cleared and associated to facility and must be removed untll then.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
Christine Yee
LICENSING EVALUATOR NAME:
Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE:
12/10/2021
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/10/2021
LIC809
(FAS) - (06/04)
Page:
2
of
9
Document Has Been Signed on
11/14/2022 08:39 AM
- It Cannot Be Edited
Created By:
Alberto Lopez
On
12/10/2021
at
04:39 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 CNTR DR. ST 500
MONTEREY PARK
,
CA
91754
FACILITY NAME:
COMEAUX FAMILY HOME
FACILITY NUMBER:
191840975
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
12/10/2021
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observationThe hot water temperature in the bathrooms listed below were not in compliance with Title 22 Regulations: At 12:54am, Bathroom adjacent to Room 9 - measured at 125.6 degrees F & bathroom adjacent to room number 11 - measured at 128.4 degrees F
POC Due Date:
12/11/2021
Plan of Correction
1
2
3
4
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
Christine Yee
LICENSING EVALUATOR NAME:
Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE:
12/10/2021
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/10/2021
LIC809
(FAS) - (06/04)
Page:
5
of
9
Document Has Been Signed on
11/14/2022 08:39 AM
- It Cannot Be Edited
Created By:
Alberto Lopez
On
12/10/2021
at
04:52 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 CNTR DR. ST 500
MONTEREY PARK
,
CA
91754
FACILITY NAME:
COMEAUX FAMILY HOME
FACILITY NUMBER:
191840975
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
12/10/2021
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(d)
Criminal Record Clearance
(d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, LPA observed P1 who is not a client residing at facility without criminal background clearance
POC Due Date:
12/11/2021
Plan of Correction
1
2
3
4
Administrator will remove P1 by due date and get criminal background/live scan completed. Administrator stated P1 is leaving facility and will get background clearance and live scan proior to returning and provide LPA with proof by providing copies of the requirement,
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
Christine Yee
LICENSING EVALUATOR NAME:
Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE:
12/10/2021
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/10/2021
LIC809
(FAS) - (06/04)
Page:
7
of
9
Document Has Been Signed on
11/14/2022 08:39 AM
- It Cannot Be Edited
Created By:
Alberto Lopez
On
12/10/2021
at
04:52 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 CNTR DR. ST 500
MONTEREY PARK
,
CA
91754
FACILITY NAME:
COMEAUX FAMILY HOME
FACILITY NUMBER:
191840975
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
12/10/2021
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation At 12:15 pm Jay Murphy Ruffins, maintenance man, accompanied LPA with the tour of the remainder of the outside of the home. At 12:19pm LPA and Mr Murphy observed the 2 window screen on the back of the home in disrepair.
At 12:16 LPA and Jay Murphy observed the outside shaded area with a broken support beam and in need of repair. At 1:02 pm LPA brought up the broken support beam to the attention of the Administrator and was observed by LPA and administrator.
POC Due Date:
01/10/2022
Plan of Correction
1
2
3
4
Admiistrator will fix the broken beam that provides the cover of shade and will repair the screens that are torn. Adminstrator will submitt prove by POC Date
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
Christine Yee
LICENSING EVALUATOR NAME:
Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE:
12/10/2021
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/10/2021
LIC809
(FAS) - (06/04)
Page:
6
of
9
Document Has Been Signed on
11/14/2022 08:39 AM
- It Cannot Be Edited
Created By:
Alberto Lopez
On
12/10/2021
at
06:01 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 CNTR DR. ST 500
MONTEREY PARK
,
CA
91754
FACILITY NAME:
COMEAUX FAMILY HOME
FACILITY NUMBER:
191840975
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
12/10/2021
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
800879(a)
(a) The faclity shall be clean, safe, sanitary and in good reapir for the safety and well being of the clients and visitors
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
LPA and Mr Murphy observed the 2 window screen on the back of the home were torn
At 1:02 pm LPA observed the broken support beam for the shaded cover.
POC Due Date:
01/10/2022
Plan of Correction
1
2
3
4
Administrator will repair window screens and support beam by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
Christine Yee
LICENSING EVALUATOR NAME:
Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE:
12/10/2021
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/10/2021
LIC809
(FAS) - (06/04)
Page:
9
of
9
Document Has Been Signed on
11/14/2022 08:39 AM
- It Cannot Be Edited
Created By:
Alberto Lopez
On
12/10/2021
at
06:26 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 CNTR DR. ST 500
MONTEREY PARK
,
CA
91754
FACILITY NAME:
COMEAUX FAMILY HOME
FACILITY NUMBER:
191840975
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
12/10/2021
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
80088 (e) (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).
Deficient Practice Statement
1
2
3
4
Based on observation licensee did not comply with the section cited above. LPA and administrator observed water temperture in two bathrooms at 126.6 degress f and 128.4 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
12/11/2021
Plan of Correction
1
2
3
4
Administrator will adjust water temperture and send proff by sending photo by poc date or self certifiy
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
Christine Yee
LICENSING EVALUATOR NAME:
Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE:
12/10/2021
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/10/2021
LIC809
(FAS) - (06/04)
Page:
3
of
9