197608867-5-18-2023-11-AS-AINZ-CRXS4D-20230518133235

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608867
Report Date: 05/18/2023
Date Signed: 05/18/2023 01:32:39 PM

Document Has Been Signed on 05/18/2023 01:32 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	SANTA MONICA HOME & CARE 1		FACILITY NUMBER:	197608867
ADMINISTRATOR:	GARYSTRATHEARN/JENNIFER BL		FACILITY TYPE:	740
ADDRESS:	912-10TH STREET FRONT AND B		TELEPHONE:	(310) 576-0044
CITY:	SANTA MONICA	STATE: CA	ZIP CODE:	90403
CAPACITY:	6	CENSUS: 3	DATE:	05/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:28 AM
MET WITH:			TIME COMPLETED:	01:32 PM

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On 05/18/2023, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit with a primary focus on using the new CARE Inspection Tool. LPA met with administrator Gary Strathearn and staff Svetlana Dagala and explained the purpose of today’s visit. The facility is licensed for (6 residents), (2) non-ambulatory, (4) ambulatories and Hospice Waiver for (3). Currently, there are 3 residents, all are over the age of 60.

The facility is a one-story structure located in a residential neighborhood. The first-floor licensed facility consists of the following: four (4) resident rooms, three (3) bathrooms, living room, dining room, kitchen and enclosed patio/activity room area.

LPA and Administrator toured the physical plant. There were no bodies of water or obstructions on the premises. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature ranged from 110.5F° – 114.2F°. The room temperature ranged from 76F° – 78F°.

CONTINUE ON LIC 809C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SANTA MONICA HOME & CARE 1	FACILITY NUMBER: 197608867
	VISIT DATE: 05/18/2023

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LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage area cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. Smoke detectors were observed to be hardwired and interconnected. Facility has fire extinguishers, fully charged.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocol for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time.

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Administrator Svetlana Dagala.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023

LIC809 (FAS) - (06/04)

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