197601334-8-9-2024-11-AS-PBUR-D7YQ2R-20240809114735

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197601334
Report Date: 08/07/2024
Date Signed: 08/09/2024 11:48:43 AM

Document Has Been Signed on 08/09/2024 11:48 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	AYRES RESIDENTIAL CARE HOME		FACILITY NUMBER:	197601334
ADMINISTRATOR:	GABAI, MICHAEL		FACILITY TYPE:	740
ADDRESS:	10940 AYRES AVE.		TELEPHONE:	(310) 475-4727
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90064
CAPACITY:	6	CENSUS: 6	DATE:	08/07/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Sheree Mckay		TIME COMPLETED:	03:30 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) Pamela Bunker conducted an unannounced Required - 1 Year visit with the primary focus on Infection Control measures and using the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA was properly screened for COVID-19 symptoms and temperature was checked. LPA Bunker met with House Manager Sheree McKay and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved Mitigation Plan and Infection Control Report. There are currently 6, residents and in placement. LPA Bunker verified that current staff fingerprints were cleared and associated with the facility. The facility's annual fees are current. The facility has a Dementia Program. The facility is licensed for three (3) hospice care residents. The facility has sufficient staff available and competent to provide the services necessary to meet resident needs. The following 12 Domains will be observed and reviewed: Infection Control, Operational Requirements, Physical Plant & Environmental Safety, Staffing, Personnel Records-Staff Training, Residents Rights-Information, Planned Activities, Food Service, Incidental Medical and Dental, Resident Records-Incident Reports, Disaster Preparedness, and Residents with Special Health Needs. "LPA Bunker will be using this tool and methods that have been developed to improve the efficiency and accuracy of the Department of Social Services' facility inspections." See continued LIC809-C page 2

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: AYRES RESIDENTIAL CARE HOME	FACILITY NUMBER: 197601334
	VISIT DATE: 08/07/2024

NARRATIVE

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Continued LIC809-C page 2

The above facility is a single-story family home located in a residential neighborhood. During the visit, Ms. McKay and LPA Bunker conducted a tour of the facility, which consisted of the following areas: Living rooms, dining room, kitchen, six (6) bedrooms, seven (7) bathrooms, office, laundry room, detached garage, and indoor/outdoor activity areas. At the time of the visit, the front and back yard landscaping was well-maintained and in good condition. Bedrooms #1-6 are designated as residents’ bedrooms. The facility was evaluated to ensure it meets the safety and welfare needs of the residents, focusing on cleanliness and the absence of potential hazards. The required documents were appropriately displayed in the living room and hallway walls as mandated. The following areas, regulated under Title 22, were audited and found to be in compliance:
- Bedrooms were inspected and contained the required furniture, ensuring safety, privacy, and comfort for residents.
- Common living areas and bathrooms were clean and fully operational.
- The first aid kit, including a manual, was fully stocked.
- Hot water temperature was measured at 115 degrees Fahrenheit.
- The facility's telephones were operational, and smoke and carbon monoxide detectors were in compliance and functioning properly.
- Fire extinguishers were fully charged.
- Medications were centrally stored and securely locked in the office cabinet, with records maintained up-to-date.
- An ample supply of both perishable and nonperishable food was available.
- Adequate linen supplies and sufficient lighting were observed throughout the premises.
- Resident bedroom windows were compliant, with no sliding window locks with thumbscrews.
- There were no firearms on the premises, and all exit doors were in compliance.
- The yard was free of debris and hazards, with trash cans properly covered and no bodies of water present.
- Hazardous items were inaccessible to residents. See continued LIC809-C page 3

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: AYRES RESIDENTIAL CARE HOME	FACILITY NUMBER: 197601334
	VISIT DATE: 08/07/2024

NARRATIVE

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Continued LIC809-C page 3

Ms. McKay confirmed that staff had received training on dependent adult and elder abuse reporting. The most recent Fire/Emergency Drill was conducted on July 8, 2024.

LPA Bunker observed the facility’s infection control practices, screening protocols for residents and visitors, sanitizer, visitor log, and thermometer at the facility entrance. Logs of daily COVID-19 screening and temperature checks of clients and staff were available and updated. PPE supplies are readily available to staff, and an additional supply of Personal Protective Equipment (PPE) was observed. Sufficient liquid soap, paper goods, cleaning, and disinfecting supplies were observed.

Due to time constraints, LPA Bunker will return at a later date to complete the visit.

There were no deficiencies cited.

Exit interview conducted.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

LIC809 (FAS) - (06/04)

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