197607893-5-19-2024-28-AS-JVIS-D5ET37-20240519142151

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607893
Report Date: 05/19/2024
Date Signed: 05/19/2024 02:22:24 PM

Document Has Been Signed on 05/19/2024 02:22 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
CCLD Regional Office, 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: 2	DATE:	05/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:35 AM
MET WITH:	Staff David Berry		TIME COMPLETED:	02:30 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) Jose Villalobos conducted the unannounced Annual Inspection visit using the Compliance And Regulatory Enforcement (CARE) Tool. LPA met with Staff David Berry and the purpose of the visit was discussed. The following tool domains were completed: 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. Physical Plant and Environmental Safety: The facility is licensed to serve up to (4) non-ambulatory residents ages 60 and older. The facility is a single-story home located in a residential area. A tour of the facility includes: living room, dining room, kitchen, (3) client bedrooms, 1 staff room, 2 bathrooms, laundry room, attached garage, front yard, and backyard. There are currently (2) ambulatory residents serviced by South Central Los Angeles Regional Center. There are no bodies of water on the premises. The facility was inspected during the physical plant tour. No passageways or paths were obstructed. Water temperature in bathrooms tested at 114 and 115 degrees. The knives and sharp items are stored in a locked cabinet. Smoke and carbon monoxide detectors operational. The fire extinguisher was observed and is fully charged. Operational Requirements: Facility is operating within its approved clearance as there are only (2) Residents of which both are ambulatory. Activities Calendar observed. Liability insurance is maintained. Personnel Records-Training: Personal records centrally stored. LPA inspected six (6) staff files. All staff are background check cleared and associated with the facility. All the staff files have the required Title 22 documents. The administrators certificate is currently active. Continued on LIC 809-C

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2024

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: C-H #6 RESIDENTIAL CARE FOR ELDERLY	FACILITY NUMBER: 197607893
	VISIT DATE: 05/19/2024

NARRATIVE

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Staffing: The facility has a sufficient amount of staff per shift in the facility. LPA reviewed staff roster to verify that there is a staff present during the Nightshift.

Resident Rights-Information: Resident personal rights poster was observed. Other required postings also observed.

Resident Records-Incident Reports: LPA reviewed (2) Resident Files during the visit. Resident files are kept locked in a file cabinet and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plans.

Planned Activities: There are sufficient activities readily available for residents in care. Sufficient space for activities was observed.

Food Service: Supply of Non perishables and perishables was observed. Food supply was adequately stored. Pesticides and other toxic substances were not stored with the food supply. Kitchen area was clean. Food menu was observed.

Incidental Medical & Dental: All medications for residents are centrally stored and kept locked and inaccessible to other residents in care. LPA reviewed (2) Resident medications supply. No medication errors were observed.

Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Last emergency drills conducted on 4/4/24

Residents with Special Needs: There are no residents who are bedridden or in need of postural supports in the facility. There are no residents in care receiving hospice services. There are no residents in care with prohibited health conditions. There are no residents in care with dementia. There is (1) residents in care receiving Home Health services for incidental medical care. Home health plan observed.

Per Title 22 Regulations, no deficiencies are being cited on todays visit.
Exit Interview conducted. A copy of the report was provided

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2024

LIC809 (FAS) - (06/04)

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