197602786-2-21-2023-28-AS-AGOZ-CP9NAR-20230221091757

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197602786
Report Date: 02/17/2023
Date Signed: 02/21/2023 09:18:32 AM

Document Has Been Signed on 02/21/2023 09:18 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:	ARDMORE GUEST HOME		FACILITY NUMBER:	197602786
ADMINISTRATOR:	BERNADETTE E. MANALO		FACILITY TYPE:	735
ADDRESS:	178 S. ARDMORE AVENUE		TELEPHONE:	(213) 674-7358
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90004
CAPACITY:	6	CENSUS: 5	DATE:	02/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Amor Aquino		TIME COMPLETED:	10:30 AM

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) Alma Gonzalez conducted an unannounced Annual Required / Infection Control visit to the above facility. LPA was met by Facility Staff Amor Aquino and the purpose of today’s visit was explained. The facility is licensed to serve six (6) Developmentally Disabled Clients ages 18 - 59 years. The facility is approved for 2 Ambulatory Clients and 4 Non-Ambulatory clients. LPA Gonzalez and Staff Amor Aquino toured the entire facility inside and outside. The home is located in a residential area and consists of (3) Client Bedrooms, (3) Bathrooms, Living Room, Kitchen, Family/ Recreation room, Office and Dining area. During inspection of client rooms; LPA observed the following: mattresses and box springs in good condition, adequate lighting present, client bedrooms had plenty of dresser and closet space. LPA observed that bed linens, comforters, and bath towels are adequately stocked. Bathrooms were found to be within Title 22 regulations. Toilets and water faucets worked properly. Bathroom sinks and showers were free of mold/mildew. LPA observed that sufficient toiletries accessible to clients. Water temperature properly measured at 118 degrees F. All medications for clients are kept locked and inaccessible to clients. The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and seven (7) days of non-perishables. All storage areas for cleaning solutions, toxins, knives, and hazardous items are in a secured cabinet in laundry room and inaccessible to facility clients. The front and back yards are both well landscaped. A shaded area with were chairs is provided in the back yard. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. Facility was observed to be in good repair. Report continues on LIC809C)

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ARDMORE GUEST HOME	FACILITY NUMBER: 197602786
	VISIT DATE: 02/17/2023

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The following were observed/inspected:

COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility, and in all common rooms bathrooms and hallways.
Clients are able to use a designated isolation room that will be used as isolation room if a COVID-19 positive case should arise.
30 day supply of medication for clients
Facility has an adequate amount of PPE and facility has enough PPE for 3 months.
Clients were socially distanced according to local public health guidelines.
Staff responsible for direct care and supervision were observed wearing masks.
Hand Sanitizer: Available throughout the facility for client use.
The clients temperature's are checked and logged once a day.
Staff temperatures are checked and logged twice a day or anytime shift changes.
Staff and clients are tested weekly for COVID-19.

Exit interview conducted, a copy of this report was provided to Facility Staff Amor Aquino

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023

LIC809 (FAS) - (06/04)

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