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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803285
Report Date: 08/03/2023
Date Signed: 08/03/2023 12:02:02 PM

Document Has Been Signed on 08/03/2023 12:02 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:CARFAX HOMEFACILITY NUMBER:
197803285
ADMINISTRATOR:LUZ H. RASCOFACILITY TYPE:
735
ADDRESS:4313 CARFAX AVENUETELEPHONE:
(562) 627-9612
CITY:LAKEWOODSTATE: CAZIP CODE:
90713
CAPACITY: 4CENSUS: 3DATE:
08/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:54 AM
MET WITH:Luz Rasco - AdministratorTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility using the CARE Tool. LPA Mora met with Luz Rasco (Administrator) and explained the reason for the visit. The facility is licensed to serve one non-ambulatory and three ambulatory clients ages 18-59. Facility is operating within the scope of it's license.

A tour of the single-story facility included the living room, dining room, kitchen, 4 client bedrooms, 2 client bathrooms, laundry area, front yard, backyard, and detached garage/office room. LPA Mora conducted the tour with Luz Rasco and observed the following: sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables were observed in the kitchen. Sharps were observed locked in a kitchen cabinet. Chemical and cleaning solutions are kept locked in a cabinet above the washer and dryer and also under the kitchen sink. The First Aid kit is kept above the medication cabinet and it is fully stocked with all required items including a current manual. Clean towels and extra clean linen were observed in the hallway cabinet. Dining and living room have sufficient lighting and sitting area. Medications are kept locked in a cabinet near the kitchen. Client and staff files are kept in the garage/office room. All bedrooms have all required furniture, lighting, and bedding. All bathrooms were observed with shower mats. The water temperature was tested in both bathrooms and measured at 117.1 degrees F and 113.1 degrees F, which is within the required 105-120 degrees F. A fire extinguisher was observed in the kitchen and it is fully charged. The fireplace has a fence cover. Smoke detectors were observed throughout the facility and in each room and were operable during the visit. There is one carbon monoxide located in the kitchen and was operable during the visit. The front yard and backyard are clean. There is a shaded area with seating in the backyard. No bodies of water were observed at the facility. Passageways and exits are free of obstruction.

LPA reviewed medication for 3 client and observed that medication was not given as prescribed for 2 clients (Refer to LIC 809-D for full details). LPA reviewed files for all 3 clients and 3 staff. LPA observed administrator certificate for Luz Rasco - 6010894735 with an expiration date of 02/18/2024. LPA interviewed 2 staff. The clients were unavailable to interview. LPA reviewed P&I funds for 3 clients with administrator present. Facility has the required surety bond and it expires on 04/18/2024. (Continued to LIC 809-C)
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2023
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: CARFAX HOME
FACILITY NUMBER: 197803285
VISIT DATE: 08/03/2023
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Per California Code of Regulations, Title 22, and California Health and Safety Code, there was one deficiency observed during the visit. Please refer to LIC 809-D. Exit interview held and a copy of the report and appeal was provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/03/2023 12:02 PM - It Cannot Be Edited


Created By: Luis Mora On 08/03/2023 at 11:41 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CARFAX HOME
FACILITY NUMBER: 197803285

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 3 clients, which poses an immediate health, safety or personal rights risk to persons in care. C1 was not given the evening medication Doxycycline Hyclate 20MG on 08/02/2023 and C2 was not given the bedtime medication Cetirizine HCL 10MG on 08/02/2023.
POC Due Date: 08/04/2023
Plan of Correction
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Administrator is to notify C1 and C2's physicians regarding the missed medications. Administrato will conduct and in-service medication training with all staff and submit list of attending staff members to CCLD by 08/11/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Wei Siew Ho
LICENSING EVALUATOR NAME:Luis Mora
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2023


LIC809 (FAS) - (06/04)
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