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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607231
Report Date: 08/25/2022
Date Signed: 08/25/2022 01:00:22 PM


Document Has Been Signed on 08/25/2022 01:00 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:A HELPING HAND SOUTH BAYFACILITY NUMBER:
197607231
ADMINISTRATOR:SUSAN COOPERFACILITY TYPE:
740
ADDRESS:4848 134TH PL.TELEPHONE:
(310) 973-1315
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY:6CENSUS: 6DATE:
08/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Connie ClabueschTIME COMPLETED:
12:00 PM
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LPA Perry Scott conducted an unannounced 1-year Annual Inspection, with an emphasis on infection control, at the A Helping Hand facility on 08/25/22. LPA Scott met with facility caregiver Connie Clabuesch. The staff caregiver was informed of the purpose of the 1-year Annual Inspection visit and assisted with the tour of the facility. Currently the home has (5) ambulatory residents, and (1) non-ambulatory resident; and a hospice waiver approved for 3. All six residents are over the age of 59. As part of the inspection, LPA Scott reviewed: client service records, client medication records, and checked for appropriate signage (e.g., covid-19, Emergency Information, Personal Rights, etc.) to insure COVID guidelines were followed.

LPA Scott and Clabuesch, toured the entire facility inside and outside grounds. Upon entry, all appropriate COVID-19 questions were asked, and my temperature was checked. However, there was not a sign in sheet for the facility to keep track of all visitors and temperatures that were checked. The one-story residential house consisted of (5) residential bedrooms, (3.5) bathrooms, living room, family room, dining room, kitchen, and enclosed patio area. All facility rooms are clean and in good repair. LPA observed the residents in the kitchen area watching television, and everyone seemed content. LPA also observed the following during inspection of resident’s rooms: mattresses and box springs were in good condition, adequate lighting was present, plenty of dresser/closet space, and all bed linens were in order. Report continued form LIC 809-C.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2022
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 3


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: A HELPING HAND SOUTH BAY
FACILITY NUMBER: 197607231
VISIT DATE: 08/25/2022
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LPA Scott also observed that there were sufficient bedding, linens, and towels accessible to clients, and observed fully stocked bedding and towels in the hall closet. Additionally, LPA Scott observed the bathrooms, and they were found to be within Title 22 regulation. Bathroom fixtures are clean, in good repair, and working properly; and had the required grab bars and non-skid floor mats. Water temperature properly measured at 106.5 degrees F for the facility. Perishable (7 day) and non-perishable (2 day) food supply were checked and are adequately stocked.

Smoke/carbon monoxide detectors are hard-wired throughout the facility, they were tested and working properly. The facility (1) Fire Extinguisher was fully charged and accessible and last serviced on 04/12/22. Further, the last fire drill occurred on 08/13/22.

All toxins and knifes are locked/secured and inaccessible to residents. Medications are centrally stored and in a locked storage cabinet. Facility first aid kit and manual was checked and in order. Outside grounds were toured and no bodies of water were observed. Outside patio is accessible to clients. All Exits/ Walkways around the home were free of debris and hazards.

LPA gave the facility a technical advisory because there wasn’t a sign in book at the screening point.

During the visit, LPA observed the following to be complying: the facility's infection control practices; screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms; every staff was wearing a face covering; the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has a Mitigation Plan Report approved by CCLD. Report continued form LIC 809-C

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022
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: A HELPING HAND SOUTH BAY
FACILITY NUMBER: 197607231
VISIT DATE: 08/25/2022
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According to the California Code of Regulations (Title 22, Division 6, Chapter 1), there were no deficiencies cited.

An exit interview was conducted, and a copy of the report was furnished to Connie Clabuesch.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022
LIC809 (FAS) - (06/04)
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