197607893-6-2-2023-28-AS-THEA-CSEQW9-20230602123134

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607893
Report Date: 06/02/2023
Date Signed: 06/02/2023 12:32:33 PM

Document Has Been Signed on 06/02/2023 12:32 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	C-H #6 RESIDENTIAL CARE FOR ELDERLY		FACILITY NUMBER:	197607893
ADMINISTRATOR:	FISHER-ASHLEY, ADLEAN		FACILITY TYPE:	740
ADDRESS:	8726 DORIAN ST		TELEPHONE:	(562) 633-3612
CITY:	DOWNEY	STATE: CA	ZIP CODE:	90242
CAPACITY:	4	CENSUS: 3	DATE:	06/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Adlean Fisher-Ashley - Administrator		TIME COMPLETED:	12:45 PM

NARRATIVE

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Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Administrator Adlean Fisher-Ashley. The facility is licensed to serve 4 non-ambulatory residents ages 60 and older.

The facility is a single-story home located in a residential. A tour of the facility includes: living room, dining room, kitchen, 2 client bedrooms, 1 staff room, 2 bathrooms, laundry room, attached garage, front yard, and backyard.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents’ medications. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan posted.

Physical Plant & Environment Safety: There are 2 client bedrooms, 1 staff room, 2 bathrooms, living room, dining room, kitchen, attached garage, front yard, and backyard. Residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available and stored in the bathrooms. The hot water temperature was tested in both bathrooms and measured between 113.7 and 116.6 degrees F which is within the required range of 105-120 degrees. All storage areas for cleaning solutions, toxins, knives, and hazardous items are centrally stored and kept locked inaccessible to clients. During todays visit LPA observed cleaning supplies stored in an unlocked cabinet in resident bathroom and in laundry room which poses an immediate health and safety violation to residents in care. The last Fire/Emergency Drill was conducted on 06/2/23. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged.
(Continued on 809-C)

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

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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Document Has Been Signed on 06/02/2023 12:32 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: C-H #6 RESIDENTIAL CARE FOR ELDERLY	FACILITY NUMBER: 197607893
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in as disinfectants and cleaning solutions in laundry room and clients bathroom were stored in unlocked cabinets making them accessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/02/2023
	Plan of Correction
1 2 3 4	Administrator to ensure that all storage areas for disinfectants, cleaning solutions, and poisons shall be locked at all times. During todays visit administrator placed and locked both cabinets making cleaning solutions and disinfectants inaccessable to residents in care. Administrator will provide training to all staff regarding the storage of the disinfectants, cleaning solutions and poisons. Submit a copy of the staff attendance log with a copy of the training material to Licensing by 6/26/23.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: C-H #6 RESIDENTIAL CARE FOR ELDERLY	FACILITY NUMBER: 197607893
	VISIT DATE: 06/02/2023

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Operational Requirements: There are currently 3 non-ambulatory residents residing at the facility.
Staffing: There appears to be sufficient staffing at all times in the facility. Administrator Adlean Fisher-Ashley certificate expires on 05/23/24.
Personnel Records-Training: Staff has criminal record clearance and current First Aid/CPR and sufficient on-going training. Staff files are maintained in a locked cabinet in staff room.
Resident Rights-Information: Resident personal rights poster is posted in the dining room.
Resident Records-Incident Reports: Resident files are kept locked in a file cabinet located in the staff room and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan.
Planned Activities: There are sufficient activities readily available for residents in care.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Incidental Medical & Dental: All medications for residents are kept locked in front closet and are inaccessible to other clients.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites.
Residents with Special Needs: There are no residents who are bedridden or in need of postural supports in the facility.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during today’s visit are documented on 809D.

Exit interview was held, a copy of the report and appeal rights were provided to Administrator Adlean Fisher-Ashley.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC809 (FAS) - (06/04)

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