197607774-12-28-2023-11-AS-ARID-CYXVNC-20231228153456

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607774
Report Date: 12/28/2023
Date Signed: 12/28/2023 03:35:03 PM

Document Has Been Signed on 12/28/2023 03:35 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:	RICH RESIDENTIAL CARE, LLC		FACILITY NUMBER:	197607774
ADMINISTRATOR:	DEVIN HENDRICK		FACILITY TYPE:	740
ADDRESS:	9417 HAAS AVENUE		TELEPHONE:	(323) 757-7390
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90047
CAPACITY:	5	CENSUS: 5	DATE:	12/28/2023
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	GENTRY RICHARDSON		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 12/28/28, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced Annual/Random using the new CARE Inspection Tool. LPA Richard met Licensee Gentry Richardson and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved mitigation plan report. There are currently five (5), South Central Los Angeles Regional Center (SCLARC) Residential Care For Elderly (RCFE) consumers in placement. The facility's annual fees are current. The following Domain will be observed and reviewed: Infection Control Practices "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." The facility is a single-family home located in a residential neighborhood. Licensee Richardson and LPA Richard toured the facility which consisted of the following: Living room, kitchen, dining area, 4 bedrooms, one (1) bedroom designated as staff room/office, 2 bathrooms, laundry area in the garage, locked medication closet, a locked supply closet, shaded area, indoor/outdoor activity areas, and a detached garage. The front and back yard landscape is in good condition at the time of the visit. See continued LIC809-C on page 2

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonine Richard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023

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

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: RICH RESIDENTIAL CARE, LLC	FACILITY NUMBER: 197607774
	VISIT DATE: 12/28/2023

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
26
27
28
29
30
31
32

Continued LIC809-C page 2

Documents are posted as mandated. Bedrooms contain the furniture mandated, Bathrooms are clean and operational. Personal accommodations were observed for safety, privacy, comfort, and non-skid surface mats. The kitchen was observed for the ability to prepare and serve food. The food service was reviewed for appropriate quantity and proper storage; there was an ample supply of perishable and nonperishable food. The resident’s medications were reviewed for proper storage, documentation, and system implementation. Medications are locked, and records are current. Common areas were observed for the ability to safely serve the needs of the residents, including cleanliness, and clearness of any potential hazards to the residents. The first aid kit is fully stocked with manual, smoke, and carbon monoxide detectors were in compliance. The hot water temperature measured at 108.8F degrees Fahrenheit within the normal limits (105-120F degrees), the fire extinguisher is fully charged, adequate linen supply, the facility telephones are working, resident. The client's bedroom windows have no sliding window lock with thumbscrews, all exit doors were in compliance, the yard was free of debris hazards, and trash cans were covered. Staff was given training on dependent adult and elder abuse reporting.

There were no deficiencies cited. Exit interview conducted a copy of this report was provided to Licensee Richardson

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonine Richard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2