197607735-6-12-2023-11-AS-WGIS-CSQRQR-20230612131359

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607735
Report Date: 05/01/2023
Date Signed: 06/12/2023 01:14:26 PM

Document Has Been Signed on 06/12/2023 01:14 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:	4219 W. 162ND STREET HOME		FACILITY NUMBER:	197607735
ADMINISTRATOR:	MELANIE M ESTEPA		FACILITY TYPE:	740
ADDRESS:	4219 W. 162ND STREET		TELEPHONE:	(424) 247-8936
CITY:	LAWNDALE	STATE: CA	ZIP CODE:	90260
CAPACITY:	3	CENSUS: 3	DATE:	05/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Melanie Estepa		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 05/01/23, Licensing Program Analyst (LPA) Wendy Gibbs conducted an unannounced required annual visit using the full CAREs Inspection Tool. LPA met with Administrator, Melanie Estepa and explained the purpose of today’s visit. The facility is licensed to serve elderly developmentally disabled residents ages 60 years and older, cleared for three (3) non-ambulatory residents. During the time of visit all three (3) residents were present, involved in their virtual day program. Structure The facility is a single-story home in a residential neighborhood. The facility has three (3) client rooms, two (2) bathrooms, kitchen, dining room, living room, office space, and a detached garage, and laundry/storage area. Physical Plant LPA walked the outside of the facility. LPA observed a shaded patio with a table and chairs available for resident use. Additionally, there is a shaded chair swing. The front and back are landscaped and well maintained. LPA did not observe any bodies of water. All walkways were clean, clear, and free of obstructions, hazards, and debris. All gates and exits are easily accessible. Bedrooms All bedrooms were toured. LPA observed all rooms to have the required furniture including a bed, dresser(s), nightstand with lamp, and chair(s). All beds had the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillow. LPA observed ample lighting in all the bedrooms. Bathrooms Both bathrooms were toured and meet Tittle 22 regulations. LPA observed the bathrooms to be clean and free of mold or mildew. The toilet, faucets and showers are in good working repair. The safety grab bars are secured. LPA observed a nonskid mat and chair in the shower. The water temperature measured 116.9- and 117.6-degrees Fahrenheit. Kitchen LPA toured the kitchen and found it to be clean and sanitary. All appliances are in good working repair. LPA observed an ample supply of cutleries, pots, and pans to be in good repair. LPA observed a three (3) day supply of perishable and a seven (7) day supply of nonperishable food. Additionally, in the garage is an extra supply of canned goods, multiple 5-gallon bottles of water, and a refrigerator with food. Water temperature measured 117.9 degrees Fahrenheit. Knives and other sharps are secured in a locked drawer in the kitchen.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

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: 4219 W. 162ND STREET HOME	FACILITY NUMBER: 197607735
	VISIT DATE: 05/01/2023

NARRATIVE

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Linens & Hygiene Extra linens were stored in each client’s individual closets. LPA observed towels and personal care products were stored on shelves and in a cabinet in the bathroom. An additional supply of hygiene products are stored in a cabinet in the laundry/storage room.
Cleaning Supplies All cleaning supplies, toxins, and equipment are stored in the hall closet. LPA observed an additional, ample supply of cleaning products secured and locked in the detached laundry/storage room. Safety LPA observed all exits clearly marked. A facility sketch with shut off valves marked was posted at the entrance. The smoke and carbon monoxide detectors were tested and in good working repair. There is a fully charged fire extinguisher mounted in the kitchen last serviced on 07/03/22. The last emergency drill was conducted on 04/05/23. LPA tested the working landline telephone. The First Aid kit was inspected and contained all required items with the manual. LPA observed all required signs and numbers posted. Egress systems on all doors were in good working order. There are no firearms or ammunition stored on the premises.
File Review LPA reviewed all resident files and found they contained the required documents. LPA reviewed five (5) staff files and found they contained the required documents, training, and certification. LPA reviewed the three (3) residents P & I for the past year. LPA reviewed the surety bond. LPA reviewed the training logs for staff. LPA received a copy of the Liability Insurance.
Interviews LPA interviewed two (2) residents, one (1) was sleeping. All residents interviewed were happy and felt they are treated well. LPA interviewed the three (3) staff present. All staff were able to explain the facilities process and procedures and the personal rights of clients.
Medications Centrally stored medications were observed stored in their originally received containers. All medications were secured in a locked drawer and are inaccessible to residents in care. LPA reviewed the MARs and medications for each resident.
Infection Control During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance; visitors log with Covid-19 screening and temperature log. PPE supplies are readily available to staff, and an additional 90-day supply of PPE are stored in the garage. LPA observed a sufficient paper, cleaning, and disinfecting supplies in both the locked hall closet and laundry/storage area.

No deficiencies were cited.

An exit interview was conducted with Melanie Estepa and a copy of this report was provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

LIC809 (FAS) - (06/04)

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