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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802894
Report Date: 12/16/2023
Date Signed: 12/16/2023 01:31:02 PM

Document Has Been Signed on 12/16/2023 01:31 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:HOME OF (TLC-2)FACILITY NUMBER:
197802894
ADMINISTRATOR:SEMENEA, SAMUELFACILITY TYPE:
735
ADDRESS:7417 MULLER ST.TELEPHONE:
(562) 776-1339
CITY:DOWNEYSTATE: CAZIP CODE:
90241
CAPACITY: 6CENSUS: 6DATE:
12/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Samuel Semena - AdministratorTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Anca Campos and Lela Jackson, Direct Service Professionals (DSPs) and explained the purpose of the visit. The Administrator, Samuel Semenea arrived at 10:35am and assisted LPA with the inspection. The facility is licensed to care for six (6) Developmentally Disabled Adults, ages 18 through 59, ambulatory only. All clients residing at this facility receive case management services provided by South Central LA Regional Center. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The staff use disposable gloves to clean and disinfect the high touched surfaces in the common areas. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Bathrooms have soap and paper towels. Staff are adhering to infection control requirements.
Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan and submitted to CCL. Liability Insurance policy in the amount of $1,000,000.00 each occurrence and #3,000,000.00 in the total annual aggregate is valid and will expire on 06/14/2024. A fire clearance for (6) clients is in place. Surety Bond (Summa Insurance Services) is in effect with bond amount of $1000 and expires on 07/15/2027. Fire Drill was last conducted on 10/28/2023.
Physical Plant/Environment Safety: The facility is a single storey home located in a residential neighborhood, contains five (5) client bedrooms, two (2) full bathrooms, living room, kitchen, dining area, shaded backyard, and detached garage. Currently, there are six (6) clients living in the facility. Facility is a Level 4H. The interior and exterior physical plant was inspected. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, night stand, light, chair and sufficient closet space. Bathrooms have non-skid materials and contained hygiene supplies including liquid soap, paper towels, and toilet paper. Exit doors are free of any obstruction and there are no pools or large bodies of water. Backyard was inspected and has a shaded area and sitting area. Detached garage was inspected and there is an extra refrigerator/freezer to stock up additional food items. Kitchen knives, sharps objects are kept locked in a standing cabinet in the kitchen area and inaccessible to clients. The cleaning supplies and toxic substances are stored in a locked cabinet. The facility does not have a fireplace or open faced heater. There is one (1) fire extinguisher observed to be fully charged and serviced on 04/13/2023. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. Water temperature readings measured at 115.1 deg F in bathroom #1 and 111.2 deg F in bathroom #2 and were within the required 105 - 120 degrees Fahrenheit. *****CONTINUED ON LIC809-C******
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2023
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HOME OF (TLC-2)
FACILITY NUMBER: 197802894
VISIT DATE: 12/16/2023
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Staffing: A total of eighteen (18) staff members plus the (2) Administrators provide care and supervision to the clients. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility.
Personnel Records/Staff Training: Reviewed files for three (3) staff. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Samuel Semenea, Administrator's certificate expired on 09/14/2023 and submitted renewal to CCL on 06/20/2023. Proof of renewal such as copy of the check and mail receipt were provided to LPA. Administrator has HIV training on 02/26/2023 and Tuberculosis training completed on 02/22/2023.
Client Rights-Information: Client personal rights are posted. Per Administrator, facility provides internet services to all clients and have access to the facility phone. Administrator also stated two (2) of the clients have their own personal cell phones and none of the clients have their own tablets. LPA conducted (4) client interviews during the visit.
Client Records-Incident Reports: LPA reviewed Client files for C1 through C3. Client files are maintained at the facility. Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Individual Program Plan (IPP), Behavioral Reports, Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights observed.
Food Service: There are sufficient food supplies of 2-day perishable but insufficient supply of 7-day non-perishable items. Additional food supplies were purchased during the visit. The food is properly stored in the refrigerator. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.
Health Related Services: The medications are centrally stored and in their original containers. Medications were reviewed for four (4) clients to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician.
Incidental Medical Services: There is no client at this home with incidental medical services and none have a restricted health condition.
Disaster Preparedness: The facility does have a complete Emergency Disaster and Mass Casualty Plan, however it was dated 09/24/2019. LPA asked Administrator to update the contact information on the form and reminded that Administrator is responsible in updating the form as required.
Emergency Intervention: Not-Applicable.

No deficiencies cited, TA issued. Exit interview, appeals rights and a copy of this report was provided to the Administrator, Samuel Semenea.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2023
LIC809 (FAS) - (06/04)
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