197600954-8-8-2024-11-AS-TWAN-D7Y27E-20240808170838

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197600954
Report Date: 08/08/2024
Date Signed: 08/08/2024 05:08:45 PM

Document Has Been Signed on 08/08/2024 05:08 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	MAIN GATE B & C		FACILITY NUMBER:	197600954
ADMINISTRATOR:	KHALSA, KAUR KRISHNA		FACILITY TYPE:	735
ADDRESS:	2179 WEST 21ST STREET		TELEPHONE:	(323) 734-8014
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90018
CAPACITY:	6	CENSUS: 5	DATE:	08/08/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	KRISHNA KHALSA - ADMINISTRATOR & CAMILLA CUELLAR		TIME COMPLETED:	04:45 PM

NARRATIVE

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On 08/08/2024 at 09:15 AM Licensing Program Analyst (LPA) Troy Watson conducted an unannounced annual required visit. LPA met with the Administrator Krishna Khalsa and the Co- Administrator Camilla Cuellar. The facility is licensed for (6) developmentally disabled or mentally ill adults ages 18 - 59. Currently the home has (5) clients.

The facility is a two-story structure located in a residential neighborhood and consists of the following: (3) client bedrooms, three (3) client bathrooms (1) living room area (1) dining area, (1) kitchen, one outside patio area, activity room, tv room and a front porch area and a laundry room area.

LPA Troy Watson toured the inside and outside of the facility with the Co-Administrator Camilla Cuellar. All client rooms were checked. Mattresses and box springs were in good condition. Adequate lighting and lamps were present and working. There was plenty of dresser chairs and closet space in each client bedroom.

Evaluation Report continues LIC 809-C

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (424) 544-1088
LICENSING EVALUATOR NAME: Troy Watson	TELEPHONE: (424) 544-1069
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: MAIN GATE B & C	FACILITY NUMBER: 197600954
	VISIT DATE: 08/08/2024

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Bed linens, comforters and bath towels were adequately stocked at the time of visit. The bathrooms were found to be within Title 22 regulations. Toilets and water faucets worked properly. The bathtub was free of mold/mildew. The water temperature properly measured between 105 F and 120 F in the bathrooms and in the kitchen.

LPA Troy Watson observed the facility clean, sanitary, and appropriately furnished at the time of the visit. The kitchen, and refrigerators was fully stocked with food both deep freezers were also stocked with food. The administrator has (5) smoke detectors AND (2) carbon monoxide detectors that have been tested and found operational. Toxins and knives were locked and inaccessible to clients. Medications were inspected and accounted for at the time of inspection. The first aid kit was checked and fully stocked with a certified manual . LPA reviewed the facility disaster plan. The facility disaster plan was current and in compliance with Title 22 at the time of visit. Staff records and P&I were presently available for immediate review and inspection.

An exit interview was conducted, with the Administrator Krishna Kalsa and a copy of this report was provided.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (424) 544-1088
LICENSING EVALUATOR NAME: Troy Watson	TELEPHONE: (424) 544-1069
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/08/2024 05:08 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: MAIN GATE B & C	FACILITY NUMBER: 197600954
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

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
1 2 3 4	Based on observation interview record review, the licensee did not comply with the section cited above.which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/09/2024
	Plan of Correction
1 2 3 4	P.O.C. clear due visit.

Type A

Section Cited

CCR

8088(e)(1)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 08/09/2024
	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: Stephanie Cifuentes	TELEPHONE: (424) 544-1088
LICENSING EVALUATOR NAME: Troy Watson	TELEPHONE: (424) 544-1069
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/08/2024 05:08 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: MAIN GATE B & C	FACILITY NUMBER: 197600954
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80066(a)(11)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation andrecord review the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/22/2024
	Plan of Correction
1 2 3 4	Administrator will provide current TB test results by either fax or email 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: Stephanie Cifuentes	TELEPHONE: (424) 544-1088
LICENSING EVALUATOR NAME: Troy Watson	TELEPHONE: (424) 544-1069
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

LIC809 (FAS) - (06/04)

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