197600344-5-18-2024-28-AS-MGFS-D5DQZN-20240518123701

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197600344
Report Date: 05/18/2024
Date Signed: 05/18/2024 12:37:41 PM

Document Has Been Signed on 05/18/2024 12:37 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:	OAKWOOD RESIDENTIAL FACILITY		FACILITY NUMBER:	197600344
ADMINISTRATOR/ DIRECTOR:	LYNN LEWIS		FACILITY TYPE:	735
ADDRESS:	4743 OAKWOOD AVENUE		TELEPHONE:	(323) 957-2299
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90004
CAPACITY: 6		CENSUS: 6	DATE:	05/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Alicia Pendleton - Direct Support Staff		TIME VISIT/ INSPECTION COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool (12 domains). LPA met with Alicia Pendleton and explained the reason for the visit. The facility is licensed to serve six (6) ambulatory developmentally disabled clients (age 18-59). The facility is located in a residential area and consist of a single home with a living room, a dining room, a kitchen, (3) client bedrooms, (2) client bathrooms, (1) staff bathroom, a laundry, a lounge room, a front yard, a back yard, a back porch, and a garage. Facility is vendorized through Frank Lanterman Regional Center. LPA toured the facility with Alicia Pendleton and observed the following: Facility is clean and in good repair indoor and outdoors. Living room has a fireplace that is cover, furniture is in good repair. Dining room has sufficient furniture. Kitchen is clean and in good repair. Sufficient food supplies were observed for at least 2 days of perishables and 7 days of non-perishables. Sharps are locked in a small drawer in the kitchen. Cleaning and grooming supplies were observed locked in the laundry area. Medication was observed locked in the hallway next to client's bedrooms. Each client bedroom (3) has the required furniture, bedding supplies, and sufficient lighting. Bathrooms (2) are clean and in good repair, water temperature was tested between 105.0 - 108.5 degrees F., which is within the required 105-120 degrees F. Lounge area has some activities for clients. Back porch provides a cover seating area. Backyard is clean and provides a basketball court. Garage was observed and is used as a storage area and provides a computer area for clients to used. No large bodies of water were observed. Carbon Monoxide/Smoke detectors were tested and are in working condition. Fire extinguishers were observed and last checked on 1/11/24. LPA Flores reviewed files and medication for 5 clients and 5 staff files. Administrator certificate for Lynn Lewis #600585735 exp. date: 7/20/21 was observed in administrator file. Per administrator the documents were submitted to the department for renewal. (CONT. ON LIC 809C)

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2024

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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Document Has Been Signed on 05/18/2024 12:37 PM - It Cannot Be Edited

Created By: Mary G Flores On 05/18/2024 at 12:03 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: OAKWOOD RESIDENTIAL FACILITY	FACILITY NUMBER: 197600344
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85064(k)

Administrator Qualifications and Duties

(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in HIV/TB training on file for Administrator Lynn Lewis was dated 3/15/09 which is not within the last 2 years which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/28/2024
	Plan of Correction
1 2 3 4	Administrator will obtain HIV/TB training and submit a copy of certificate to the department by POC due date 5/28/24.

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:

Tony Vasallo

LICENSING EVALUATOR NAME:

Mary G Flores

LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: OAKWOOD RESIDENTIAL FACILITY	FACILITY NUMBER: 197600344
	VISIT DATE: 05/18/2024

NARRATIVE

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Assistant administrator Esther Garcia's certificate exp. 8/21/23 and documents have also been submitted. Due to both being out of town they were not able to provide copies of submitted documents during this visit but will submit documents to the department by 5/22/24. Last HIV/TB training for administrator is dated 3/15/09. Facility is following Infection Control regulations and an infection control has been submitted to the department.

LPA Flores reviewed Emergency Disaster Plan last checked on 2/2/24 and last Emergency drill was conducted on 4/30/24.

Deficiency was noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with Alicia Pendleton and a copy of this report, LIC 809D, and appeal rights were provided.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2024

LIC809 (FAS) - (06/04)

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