197607600-1-31-2024-11-AS-PBUR-D22AKG-20240131231730

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607600
Report Date: 01/11/2024
Date Signed: 01/31/2024 11:17:41 PM

Document Has Been Signed on 01/31/2024 11:17 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:	DIANE'S FAMILY & FRIENDS		FACILITY NUMBER:	197607600
ADMINISTRATOR:	DIANE SIGUR		FACILITY TYPE:	740
ADDRESS:	11235 S. VAN NESS AVE.		TELEPHONE:	(323) 755-6616
CITY:	INGLEWOOD	STATE: CA	ZIP CODE:	90303
CAPACITY:	4	CENSUS: 3	DATE:	01/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Diane Sigur		TIME COMPLETED:	12:30 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	Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced required annual visit with the primary focus on Infection Control measures and using the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA was properly screened for COVID-19 symptoms and temperature was checked. LPA Bunker met with Licensee Diane Sigur and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved Mitigation Plan Report and Infection Control Plan. LPA Bunker verified all current staff fingerprints cleared/associated with the facility. There are currently three (3) Westside Regional Center (WRC), Residential Care Facility for the Elderly (RCFE) consumers in placement. Facility annual fees are current. There are 12 Domains in the Infection Control Practices that will be observed and reviewed. "I will be using this tool and methods that have been developed to improve the efficiency and accuracy of the Department of Social Services' facility inspections." Ms. Sigur and LPA Bunker both toured the inside and outside grounds of the facility. The facility is a single-story family home located in a residential neighborhood. Ms. Sigur and LPA Bunker made a complete tour of the facility which consisted of a Living room, dining room, kitchen, three (3) bedrooms, two (2) bathrooms, laundry room, detached garage, shaded area, and indoor/outdoor activity areas. Bedrooms #1-2 are designated as residents’ bedrooms. See continued LIC809-C page #2

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

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: DIANE'S FAMILY & FRIENDS	FACILITY NUMBER: 197607600
	VISIT DATE: 01/11/2024

NARRATIVE

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Continued LIC809-C page #2

During the tour, LPA Bunker observed sanitizer, visitor log, and thermometer at the facility entrance. Logs of daily COVID-19 screening and temperature checks of clients and staff were available and updated. PPE supplies are readily available to staff, and an additional supply of PPE was observed. Sufficient liquid soap, paper goods, cleaning, and disinfecting supplies were observed.

Documents are posted as mandated on the dining room wall bulletin board. The following Title 22 Regulated areas were audited and found to be in compliance: Bedrooms contain the required furniture. Personal accommodations were observed for safety, privacy, and comfort, including grab bars, and non-skid surface mats. The living areas are clean, bathrooms are clean and operational. The first aid kit is fully stocked with manual, the hot water temperature was measured at 109 degrees Fahrenheit, working telephone, smoke and carbon monoxide detectors were in compliance, fire extinguishers are fully charged, medications were centrally stored and properly locked in the laundry room cabinet and records are current, ample supply of perishable and nonperishable food, adequate linen supply, fire/emergency drill conducted on December 31, 2023. No firearms on the premises, the resident's bedroom windows had no sliding window locks with thumbscrews, all exit doors were in compliance, covered trash cans, and no bodies of water were present. Hazardous items are inaccessible to clients, the yard is free of debris and hazards.

The Licensee Diane Sigur stated staff was given training on dependent adult and elder abuse reporting.

There were no deficiencies cited.

Exit interview conducted.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

LIC809 (FAS) - (06/04)

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