197607576-8-31-2022-11-AS-PSCT-CHTSDZ-20220831134757

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607576
Report Date: 08/31/2022
Date Signed: 08/31/2022 01:48:07 PM

Document Has Been Signed on 08/31/2022 01:48 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:	C-H #4 RESIDENTIAL CARE FOR ELDERLY		FACILITY NUMBER:	197607576
ADMINISTRATOR:	FISHER, ADLEAN		FACILITY TYPE:	740
ADDRESS:	12137 RAMONA AVE		TELEPHONE:	(562) 630-8123
CITY:	HAWTHORNE	STATE: CA	ZIP CODE:	90250
CAPACITY:	4	CENSUS: 3	DATE:	08/31/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:07 PM
MET WITH:	Christina Fuentes/Robin Perez		TIME COMPLETED:	02:00 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	On 08/31/22 LPA Perry Scott conducted an unannounced 1-year Required Annual Inspection at the C-H #4 Residential Care for Elderly facility, with an emphasis on infection control. LPA Scott met with facility representatives Christina Fuentes and Robin Perez and the purpose of the visit was explained. Upon entry, my temperature was taken, I was given hand sanitizer, and I was presented with a visitor’s log to sign in. Both staff were wearing masks. The facility has a capacity for four (4) residents. Three (3) ambulatory and one (1) non-ambulatory. Currently the home has (3) ambulatory client and (0) non-ambulatory. The facility serves residents 60 and over. As part of the inspection, my primary focus was on infection control. LPA observed the facility’s infection control practices: LPA observed a sanitizing station at the facility entrance. PPE supplies are readily available to staff, and additional supplies are stored. Sufficient paper, cleaning, and disinfecting supplies were observed. The facility has the mandated COVID infection control posters as well as facility license, floor plan, administrators’ certificate, and emergency evacuation plan etc. Report continued form LIC 809-C.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: C-H #4 RESIDENTIAL CARE FOR ELDERLY	FACILITY NUMBER: 197607576
	VISIT DATE: 08/31/2022

NARRATIVE

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LPA Scott, Fuentes and Perez toured the entire facilities inside and outside grounds. The one-story residential house consisted of (3) client bedrooms, (2) bathrooms, living room, dining room, kitchen, and enclosed patio area. All facility rooms are clean and in good repair. LPA Scott observed the following during inspection of client rooms: mattresses and box springs in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present.

LPA Scott also observed that there were sufficient bedding, linens, and toiletries accessible to clients. Further, LPA Scott observed bathrooms were found to be within Title 22 regulation. Bathroom fixtures are clean, in good repair, and working properly. Water temperature properly measured at 106.2 degrees F for the facility. Perishable (7 day) and non-perishable (2 day) food supply were checked and are adequately stocked.

Facilities Carbon Monoxide/ Smoke Detectors (combined) were tested. All alert systems are working properly. The facilities (2) Fire Extinguisher were fully charged and accessible; and last serviced on 02/2022. Fire drill was conducted on 02/19/2022. All toxins and knives are locked/secured and inaccessible to clients. Medications are centrally stored and in a locked storage box. Facility first aid kit was checked and in order. Outside grounds were toured and no bodies of water were observed. Outside patio accessible to clients. All Exits/ Walkways around the home were free of debris and hazards. The facility is in good repair.

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 90-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has a Mitigation Plan Report approved by CCLD.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022

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: C-H #4 RESIDENTIAL CARE FOR ELDERLY	FACILITY NUMBER: 197607576
	VISIT DATE: 08/31/2022

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 26 27 28 29 30 31 32	According to the California Code of Regulations (Title 22, Division 6, Chapter 1), there were no deficiencies cited at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to facility representatives Christina Fuentes and Robin Perez.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022

LIC809 (FAS) - (06/04)

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