197610384-4-25-2023-31-AS-TCAS-CR8P8K-20230425110539

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610384
Report Date: 04/25/2023
Date Signed: 04/25/2023 11:08:01 AM

Document Has Been Signed on 04/25/2023 11:08 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	FAIR PARK MANOR		FACILITY NUMBER:	197610384
ADMINISTRATOR:	FIERRO, GILBERT		FACILITY TYPE:	735
ADDRESS:	1622 FAIR PARK AVE		TELEPHONE:	(323) 351-1524
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90041
CAPACITY: 6		CENSUS: 0	DATE:	04/25/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Gilbert Fierro		TIME COMPLETED:	11:15 AM

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Licensing Program Analyst (LPA) Tuesday Cabiness conducted a PRE-LICENSING visit to the above address 1622 Fair Park, Los Angeles, CA 90041. LPA met with Administrator/Licensee Gilbert Fierro. The inspection included, fire safety, personal accommodations, building and grounds, furniture/equipment, food service, and medication procedures. Fire Inspection was approved on February 01, 2023 which met fire department requirements. Currently, the facility is under ownership by the Licensee as a RCFE, but is changing the facility to an ARF (Adult Residential Facility). There is (1) resident living at the facility, but was not present during the visit. Facility sketch, emergency disaster plan, complaint procedures, emergency exit plan were visibly posted. LPA informed Administrator, the following signs need to be posted: client personal rights, activity calendar and visiting policy.

The physical plant was toured inside and out with Administrator Gilbert. The facility is a one level home, with (5) bedrooms, with (1) room for staff. (4) rooms will be privately used for clients. There are (4) bathrooms; but only (1) is not being used for clients or staff. Food supply was inspected and observed, and storage areas, cabinets, pantries, cupboards counters, and refrigerator were clean and appropriate for food preparation. Knives and medication were stored in cabinets located in the kitchen area. Appliances were clean and functional, and utensils, plates, and cups were in good repair. Cleaning supplies, poisons, toxins and chemicals were locked and stored in the laundry room. There was enough supply of linens and towels, which were stored in a cabinet.

The common areas included the dining, living, bathroom, and bedrooms were clean in good repair. Doors and passageways were clear and unobstructed. Walls, ceilings, floors, window screens and all other rooms were in good repair, and appropriately furnished.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: FAIR PARK MANOR	FACILITY NUMBER: 197610384
	VISIT DATE: 04/25/2023

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Resident rooms observed to have a mattress with pad, sheets, pillow, bedspread, dresser, closet space, and chair. Bathrooms were clean had functional fixtures, with soap and towels, non-skid mats, grab bars and hand washing signs were posted.

The water temperature measured at 113.0 degrees Fahrenheit. The back yard is completely fenced with a gate easily accessible and unlocked. There are no swimming pools or other bodies of water, no visible hazards around the surrounding grounds. Patio furniture was observed with table and chairs. .

Smoke detectors and carbon monoxide were operating correctly. Fire extinguisher is fully charged. Telephone installation was completed. First aid kit inspected; and a current manual needs to be purchased. Staff and client files will be stored in a locked cabinet, located in the dining room area.

COMP III was completed during the visit and Infection Control plan was reviewed and discussed.

Exit interview conducted and copy of report provided to Administrator Gilbert.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

LIC809 (FAS) - (06/04)

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