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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607576
Report Date: 09/27/2024
Date Signed: 09/27/2024 01:56:31 PM


Document Has Been Signed on 09/27/2024 01:56 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 ELDERLYFACILITY NUMBER:
197607576
ADMINISTRATOR:FISHER, ADLEANFACILITY TYPE:
740
ADDRESS:12137 RAMONA AVETELEPHONE:
(562) 630-8123
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY:4CENSUS: 2DATE:
09/27/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:House Manager - Betty WoodsTIME COMPLETED:
02:20 PM
NARRATIVE
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On 09/27/2024 at around 10:40 AM, Licensing Program Analyst (LPA) Leandro conducted an unannounced continuation Required – 1 Year Inspection to the above-named facility and met with the House Manager Betty Woods. LPA explained the purpose of the visit and was accompanied by Administrator inside and outside the facility during this inspection.

5 staff records were reviewed. 1 out of 5 staff did not have a Health Screening Report. 1 out of 5 staff did not have a negative or inactive Tuberculosis Test Result.
2 resident records were reviewed and, 2 out of 2 resident records had required documentation.

Facility records were reviewed, and facility had required documentation.

Deficiencies are being cited based on LPA record review in accordance with the California Code of Regulations, Title 22. A violation regarding Staff Medical Records. An exit interview was conducted, and a copy of this report was left with the House Manager along with Appeal Rights.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro LeandroTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024
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


Document Has Been Signed on 09/27/2024 01:56 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 ASC, 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: 09/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 5 staff not having a negative Tuberculosis test result and 1 out of 5 staff not having a Health Screening Report which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2024
Plan of Correction
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Licensee will email a negative or inactive Tuberculosis test result for Staff 3 and Licensee will email a Health Screening Report for Staff 2 to Socorro.Leandro@dss.ca.gov

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: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro LeandroTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024
LIC809 (FAS) - (06/04)
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