197607576-9-26-2024-11-AS-SLEO-D9GUE9-20240926153047

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607576
Report Date: 09/26/2024
Date Signed: 09/26/2024 03:30:58 PM

Document Has Been Signed on 09/26/2024 03:30 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 ASC, 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: 2	DATE:	09/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Staff - Thessyln Wilson		TIME COMPLETED:	04:00 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 09/26/2024 at around 1:20 PM, Licensing Program Analyst (LPA) Leandro conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with Staff Thessyln Wilson. LPA explained the purpose of the visit and was accompanied by Staff inside and outside the facility during this inspection. This facility is licensed to serve 4 adults ages 60 and above, of which 1 maybe non-ambulatory resident. A total of 2 ambulatory residents are currently residing in this facility. The facility has a balance of $495 in Annual Licensing Fees due on 10/16/2024. The facility is a one-story house located in a residential street. The home consists of 3 resident bedrooms, 2 bathrooms, 1 living room, 1 kitchen/dining room area, 1 den, 1 kitchen, 1 detached garage, 1 laundry area and 1 backyard patio area with seating.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: C-H #4 RESIDENTIAL CARE FOR ELDERLY	FACILITY NUMBER: 197607576
	VISIT DATE: 09/26/2024

NARRATIVE

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Outside grounds were toured and no bodies of water were observed. The patio furniture is under a shaded area and accessible to residents. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

LPA toured the kitchen area and observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept in locked storage cabinet.

LPA observed that medications were safe, locked, and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Documents are posted as mandated. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational. There are fire extinguishers in the dining room area. There is a landline telephone in the living room. Each client has a videoconferencing device.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

LIC809 (FAS) - (06/04)

Page: 2 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: C-H #4 RESIDENTIAL CARE FOR ELDERLY	FACILITY NUMBER: 197607576
	VISIT DATE: 09/26/2024

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3 out of 3 resident’s bedrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries accessible to residents. LPA tested hot water temperature and it measured between 105 and 120 degrees Fahrenheit. This facility provides residents with hygiene products such as feminine napkins, nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb.

Due to insufficient time LPA was unable to complete records review.

No deficiencies are being cited based on LPA observation and record review in accordance with the California Code of Regulations, Title 22.

An exit interview was conducted and a copy of this report was left with the Staff.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

LIC809 (FAS) - (06/04)

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