197607811-12-18-2023-11-AS-PBUR-CYMUF9-20231218143222

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607811
Report Date: 11/15/2023
Date Signed: 12/18/2023 02:33:52 PM

Document Has Been Signed on 12/18/2023 02:33 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:	O.V. HOMES FOR THE AGED		FACILITY NUMBER:	197607811
ADMINISTRATOR:	LISA KAYE CUMMINGS		FACILITY TYPE:	740
ADDRESS:	2421 10TH AVENUE		TELEPHONE:	(323) 731-6213
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90018
CAPACITY:	4	CENSUS: 1	DATE:	11/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Lisa Cummings		TIME COMPLETED:	03:30 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 1-year 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 Bunker was properly screened for COVID-19 symptoms and LPA temperature was checked. LPA Bunker met the Administrator Lisa Cummings and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved Mitigation Plan Report and Infection Control Report. There are currently one (1) South Central Los Angeles Regional Center (SCLARC) consumers in placement. The facility's annual fees are current. The following Domains will be observed and reviewed: Infection Control, Operational Requirements, Physical Plant/Environmental Safety, Staffing, Personnel Records/Staff Training, Resident Records/Incident Reports, Resident Rights/Information, Planned Activities, Food Service, Incidental Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs, "LPA Bunker 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. Administrator Lisa Cummings and LPA Bunker made a complete tour of the entire facility inside and outside grounds. The facility is a two-story family home located in a residential neighborhood. The facility consisted of the following: Living room, dining room, kitchen, 3 bedrooms, 2 bathrooms, laundry area in the kitchen, patio shaded area, indoor/outdoor activity areas, and a detached four (4) car garage. Bedrooms #1-2 are designated as resident's bedrooms and bedroom #3 is for live-in staff. See continued LIC809-C on page 2

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

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

FACILITY NAME: O.V. HOMES FOR THE AGED	FACILITY NUMBER: 197607811
	VISIT DATE: 11/15/2023

NARRATIVE

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Continued LIC809-C page #2

The second story has a family member living quarters, and there is a basement. The front and back yard landscape is in good condition at the time of the visit.

During the tour, LPA observed the facility’s infection control practices. LPA 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. LPA observed staff wearing a face covering and social distancing.

Documents were posted as mandated on the wall in the kitchen. The following Title 22 regulated areas were audited and found to be in compliance: Bedrooms contain the required furniture. The client’s bedrooms were inspected for safety, privacy, and comfort. The living areas are clean, bathrooms are clean and operational. The first aid kit is fully stocked with a manual, the hot water temperature was measured at 105 degrees Fahrenheit, the telephones are working, smoke and carbon monoxide detectors were in compliance, the fire extinguisher is 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 October 21, 2023. No firearms on the premises, the client's bedroom windows had no sliding window lock with thumbscrew, 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. Administrator Lisa Cummings states staff was given training on dependent adult and elder abuse reporting.

There were no deficiencies cited. LPA Bunker provided Administrator Lisa Cummings with copies of the LIC809, LIC809-C, LIC858, and LIC859 documents.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

LIC809 (FAS) - (06/04)

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