197607576-10-30-2023-11-AS-AINZ-CX4RV8-20231030132106

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607576
Report Date: 10/30/2023
Date Signed: 10/30/2023 01:21:12 PM

Document Has Been Signed on 10/30/2023 01:21 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:	10/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:36 AM
MET WITH:	Betty Woods/Staff		TIME COMPLETED:	01:20 PM

NARRATIVE

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On 10/30/2023 Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Betty Woods /staff and the purpose of today’s visit was explained. The facility is licensed to operate for (4) developmentally disabled or Mentally Ill adults ages 60 and above, of which (3) can be ambulatory and (1) non-ambulatory. Currently, the home has (3) clients. The clients are from: Westside Regional Center. (0) clients have Restricted Health Care Conditions, and (2) are utilizing postural supports or protective devices.

The one-story residential house consisted of (3) client bedrooms, (2) bathroom, living room, dining room, kitchen, and enclosed patio area.

LPA Iniguez and administrator toured the inside and outside of the facility. All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting was observed, plenty of dresser and closet space was observed. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly. Shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature properly measured between 105F°-120F° degrees (Kitchen 116.5F°, Bathroom #1 108.5°F).

Evaluation Report continues LIC 809-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023

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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: C-H #4 RESIDENTIAL CARE FOR ELDERLY	FACILITY NUMBER: 197607576
	VISIT DATE: 10/30/2023

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Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide/Smoke detectors were observed and operational (See technical advice). Fire extinguishers were fully charged, toxins and knifes were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Last facility disaster drill was:9/5/2023. Licensee will email a copy of liability insurance to LPA.

LPA conducted a records review of (3) client records, (3) staff records and reviewed the facility disaster plan. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (3) Client Medication Administration Records (MAR) and did not observe any discrepancies at the time of visit.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. (See D pages)

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to the Staff/ Betty Woods.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/30/2023 01:21 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(c)

Maintenance and Operation

(c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above in having one of the window screen ripped which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/13/2023
	Plan of Correction
1 2 3 4	Licensee will ensure window screen will be repair. A proof of correction will be sent to LPA via email before POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023

LIC809 (FAS) - (06/04)

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