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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607907
Report Date: 08/29/2024
Date Signed: 08/29/2024 11:13:08 AM


Document Has Been Signed on 08/29/2024 11:13 AM - 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245



FACILITY NAME:TWIN HOMECARE - BFACILITY NUMBER:
197607907
ADMINISTRATOR:ADELITA STUCHLAKFACILITY TYPE:
740
ADDRESS:2106 W. 242ND STREETTELEPHONE:
(424) 263-4849
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY:6CENSUS: 5DATE:
08/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Hermie Ocampo & Sarah ReyesTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Sparkle Day conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the one-year inspection. LPA met with Hermie Ocampo , caregiver and the purpose of the visit was discussed. During this visit Designated Administrator Charesa Reyes joined and assisted with the visit.The facility is licensed to serve (6) non ambulatory elderly residents ages 60 and over; of which (6) may be bedridden. There is a hospice waiver for (4) residents. There is currently (1) resident on hospice and (1) resident receiving home health services. LPA reviewed 4 staff Administrative files and 6 resident Administrative and Medication files.

The facility is a single story home consisting of 6 resident bedrooms, 1 staff bed room, 3 bathrooms, living room, dining room, kitchen, front yard, back yard/ patio,laundry room and attached garage. LPA and Ms Charesa Reyes toured the facility inside and outside. All rooms had the required furniture, bed linens and closet/drawer space required to accommodate each resident comfortably .Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured between 108 F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions.

Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

During todays visit LPA did not observe any deficiencies.

Exit interview conducted with Charesa Reyes and a copy of this report was left.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Sparkle DayTELEPHONE: (424) 544-1075
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024
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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