<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197800307
Report Date: 09/09/2024
Date Signed: 09/10/2024 08:17:32 AM

Document Has Been Signed on 09/10/2024 08:17 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:HAYES HOMEFACILITY NUMBER:
197800307
ADMINISTRATOR/
DIRECTOR:		GUZMAN,THERESAFACILITY TYPE:
735
ADDRESS:2470 HAYES AVE.TELEPHONE:
(562) 424-4930
CITY:LONG BEACHSTATE: CAZIP CODE:
90810
CAPACITY: 6CENSUS: 3DATE:
09/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Theresa Guzman, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:45 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
On 09/09/2024 at 1:15pm, Licensing Program Analyst (LPA) Zina Brown conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with the Theresa Guzman and the purpose of today’s visit was explained. The facility is licensed to operate for (2) ambulatory,(1) non-ambulatory, (0) bedridden who are developmentally disabled adults ages 18 through 59. Currently, the home has (3) clients. The clients are Harbor Regional Center clients. None the clients have Restricted Health Care Conditions and none are utilizing postural supports or protective devices.
Annual fees are due on October 11, 2024 with a balance of $454.00.

The facility is a one story home located in a residential neighborhood. The property consists of the following: five (5) bedrooms (with 3 of the room being client bedrooms), 2 common bathrooms, staff office, living room, kitchen (with water temperate at 105.0F), dining room, attached garage which houses an additional refrigerator and an outdoor shaded area.

LPA conducted a records review of (3) client records, (2) staff records, (3) clients Personal & Incidental Records and reviewed the facility disaster plan. All client & staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (3) Client Medication Administration Records and did not observed any discrepancies at the time of visit.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: HAYES HOME
FACILITY NUMBER: 197800307
VISIT DATE: 09/09/2024
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
26
27
28
29
30
31
32
At 1:25 am LPA and Theresa Guzman toured the inside and outside of the facility. All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting was observed , plenty of dresser and closet space was observed. Walls and floors were clean and in good repair. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly. Shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature properly measured between 105-120F ( Bathroom #110.0F & Bathroom #2 105.0F).

Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide detector was observed and operational. Smoke detectors were working properly, fire extinguishers were fully charged, toxins and knifes were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Outside grounds were toured and no bodies of water were observed. Exits/ Walkways around the home were free of debris and hazards.

During todays visit LPA did not observe any deficiencies.

Exit interview conducted with (EMPLOYEE NAME.TITLE).

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2