198200483-1-6-2023-11-AS-WGIS-CLLRFS-20221128115937

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198200483
Report Date: 11/28/2022
Date Signed: 01/06/2023 04:12:09 PM

Document Has Been Signed on 01/06/2023 04:12 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:	CARR HOME		FACILITY NUMBER:	198200483
ADMINISTRATOR:	CARR, TERESA M.		FACILITY TYPE:	735
ADDRESS:	5738 BRUSHTON STREET		TELEPHONE:	(323) 294-4871
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90008
CAPACITY: 6		CENSUS: 5	DATE:	11/28/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:24 AM
MET WITH:	Samuel Fairbanks		TIME COMPLETED:	12:30 PM

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Licensing Program Analyst (LPA)Wendy Gibbs conducted an unannounced visit to conduct an annual inspection using the infection control CARE tools. LPA Gibbs met with Administrator, Samuel Fairbanks and explained the purpose of the visit. The home has 5 ambulatory clients.

Structure The home consists of 3 client bedrooms, 1 staff bedroom, 2 bathrooms, living room, kitchen, dining area and family room/area.

Physical Plant Outside grounds were toured and no bodies of water were observed. There were tables and chairs on a shaded patio. All exits and walkways around the home were free of debris and hazards.

Bedrooms All client rooms were checked. Mattresses and box springs were in good condition, each bed had a mattress cover, fitted sheets, blanket, comforter and pillow. Each room had adequate lighting and required furniture such as a dresser for each resident, nightstand and closet space was observed.

Linens & Hygiene Bed linens, comforters and bath towels were adequately stocked in a closet in the hallway. Hygiene products were fully stocked.

Bathrooms Both bathrooms were in good working order. The toilets and water faucets worked properly. The shower was free of mold/mildew, had non-skid matts, and safety bars were secured. Both bathrooms had adequate lighting, and sufficient toiletries accessible to clients. Water temperature measured between 114.6-115.1 degrees F.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2022

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: CARR HOME	FACILITY NUMBER: 198200483
	VISIT DATE: 11/28/2022

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Kitchen LPA observed that all appliances were in good working order. All cutleries were in good condition. All knives were locked in drawer in the kitchen and inaccessible to residents. Perishable (3 day) and non-perishable (7 day) food supply was checked and adequately stocked. The water temperature measured 114.2 degrees F.

Fire & Safety LPA inspected first aid kit which contained all necessary items and a first aid manual. Carbon monoxide detectors were operational. Smoke detectors were working properly. LPA observed a fully charged fire extinguisher that was last serviced on 03/10/2022. All necessary numbers and documents were posted. The last emergency drill was on 11/01/2022.

Toxins All toxins were locked in the laundry room and inaccessible to clients.

File Reviews LPA reviewed all 5 client files, which all contained the necessary documents. Also, reviewed were all 4 staff files, which contained the necessary documents. Administrator certificates expire in November of 2023.

Medications All resident medications and MARs were reviewed. All medications are locked and inaccessible to residents.

Infection Control During the visit, LPA observed the facility infection control practices. LPA observed a screening station in the front entrance with sanitizer. LPA observed a sign in sheet and temperature log for visitors. The administrator screened LPA upon entry and documented LPA's temperature on the log. LPA observed administrator wearing a mask. LPA observed residents being screened after returning from day program. LPA observed required postings throughout the facility. Also observed was a minimum 30-day supply of PPEs.

There were no deficiencies cited.

Exit Interview Conducted and a copy of this report was given at the time of visit.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2022

LIC809 (FAS) - (06/04)

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