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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197600954
Report Date: 08/31/2023
Date Signed: 08/31/2023 06:35:06 PM

Document Has Been Signed on 08/31/2023 06:35 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:MAIN GATE B & CFACILITY NUMBER:
197600954
ADMINISTRATOR:KHALSA, KAUR KRISHNAFACILITY TYPE:
735
ADDRESS:2179 WEST 21ST STREETTELEPHONE:
(323) 734-8014
CITY:LOS ANGELESSTATE: CAZIP CODE:
90018
CAPACITY: 6CENSUS: 5DATE:
08/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:59 PM
MET WITH:KHALSA, KAUR KRISHNATIME COMPLETED:
06:00 PM
NARRATIVE
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On 08/31/2023 at 2:00 PM, Licensing Program Analyst (LPA) David España conducted an unannounced annual inspection visit at the Main Gate B&C Facility. LPA met with Kaur Krishna Khalsa, Administrator and staff Camilla Cuellar. Facility is licensed for 6 Developmental Disabled clients. The home currently has 5 residents in placement at time of this visit. The facility does handle residents’ money. LPA toured the physical plant, checked food service (2-week supply), reviewed staff records and reviewed resident files for medical status. The facility conducts fire drills monthly. The home consists of 3 client bedrooms, 2 staff bedrooms, 2 offices, 7 bathrooms, 2 Living rooms, Kitchen, and Dining area. All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Walls and floors were clean and in good repair. Bed linens, comforters and bath towels were adequately stocked at the time of visit.

Bathrooms were found to be clean and sanitary. Toilets and water faucets worked properly. Shower was free of mold/mildew, adequate lighting, and sufficient toiletries accessible to clients. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly and fire extinguisher was fully charged. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.


Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2023
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 4
Document Has Been Signed on 08/31/2023 06:35 PM - It Cannot Be Edited


Created By: David Espana On 08/31/2023 at 06:04 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: MAIN GATE B & C
FACILITY NUMBER: 197600954

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (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).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above.LPA and Kaur Krishna Khalsa, Administrator observed 135.2 degrees in jack and jill restroom on the second floor, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/05/2023
Plan of Correction
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The administrator/licensee agreed to have water temperature fixed for residents ensuring resident safety. The licensee shall submit plan of correction to ensure cited deficiency do no reoccur at the facility. The administrator of records shall update the resident's/staff's in services plans within date 09/05/2023.
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
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Based on observation, interview, and record review, the licensee did not comply with the section cited above. LPA and Kaur Krishna Khalsa, Administrator and staff Camilla Cuellar observed an outdated disaster preparedness form, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/08/2023
Plan of Correction
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The administrator/licensee agreed to have updated emergency disaster plan for residents ensuring resident safety. The licensee shall submit plan of correction to ensure cited deficiency do no reoccur at the facility. The administrator of records shall update the resident's/staff's in services plans within date 09/08/2023.
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: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/31/2023 06:35 PM - It Cannot Be Edited


Created By: David Espana On 08/31/2023 at 06:04 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: MAIN GATE B & C
FACILITY NUMBER: 197600954

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(a)(5)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (5) At least two appropriate shelter locations that can house or supervise, as applicable, individuals served by the facility during an evacuation. One of the locations shall be outside of the immediate area.

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 and Kaur Krishna Khalsa, Administrator and staff Camilla Cuellar observed two appropriate shelter locations, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/08/2023
Plan of Correction
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The administrator/licensee agreed to have two appropriate shelter locations for residents ensuring resident safety. The licensee shall submit plan of correction to ensure cited deficiency do no reoccur at the facility. The administrator of records shall update the resident's/staff's in services plans within date 09/08/2023 (i.e., 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: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023


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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: MAIN GATE B & C
FACILITY NUMBER: 197600954
VISIT DATE: 08/31/2023
NARRATIVE
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Physical Plant & Environmental Safety - No Deficiency: 80087(a) - LPA and Kaur Krishna Khalsa, Administrator observed front of facility window screens in disrepair.

Physical Plant & Environmental Safety - Type B: 80088(e)(1) - LPA and Kaur Krishna Khalsa, Administrator observed 135.2 degrees in jack and jill restroom on the second floor.

Personnel Records - Training - Type B: 85064(k) - LPA and Kaur Krishna Khalsa, Administrator and staff Camilla Cuellar observed an outdated disaster preparedness form.

Disaster Preparedness - Type B: 1565(a)(5) - LPA and Kaur Krishna Khalsa, Administrator and staff Camilla Cuellar observed an emergency disaster plan form.

Exit interview conducted and a copy of the appeal rights were given at the time of the visit to Kaur Krishna Khalsa, Administrator.

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

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC809 (FAS) - (06/04)
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