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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607576
Report Date: 11/23/2021
Date Signed: 11/23/2021 08:51:44 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME:C-H #4 RESIDENTIAL CARE FOR ELDERLYFACILITY NUMBER:
197607576
ADMINISTRATOR:FISHER, ADLEANFACILITY TYPE:
740
ADDRESS:12137 RAMONA AVETELEPHONE:
(562) 630-8123
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY:4CENSUS: 3DATE:
11/23/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:41 PM
MET WITH:Staff#1TIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jey Cardenas conducted a case management visit to the above facility; during a complaint investigation visit made on 11/23/21, LPA observed deficiencies that is non-related to the complaint investigation conducted on today. On 11/23/21 LPA observed a smoke detector located in resident bedroom that was wrapped in tape. S1 indicated that the smoke detector chirps at different times of day. LPA indicated that the smoke detector may have to be replaced. The following was discussed with the staff: smoke detectors shall be in working condition at all times.

Per California Code of Regulations, Title 22, deficiency is being cited on the attached LIC 809D.
Exit interview conducted copy of this report and copy of appeal rights provided to facility representative
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey CardenasTELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: C-H #4 RESIDENTIAL CARE FOR ELDERLY
FACILITY NUMBER: 197607576
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/23/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87203
87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) LPA Cardenas observed smoke detector in residents room covered with duct tape, LPA was informed that smoke detector didnt stop chirping. This poses/posed a potential health, safety risk to persons in care.
POC Due Date: 11/25/2021
Plan of Correction
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Administrator shall ensure that smoke detector located in residents room is operating.
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: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey CardenasTELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:
DATE: 11/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/23/2021
LIC809 (FAS) - (06/04)
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