198200623-9-25-2023-11-AS-DESA-CVZPXF-20230925114215

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198200623
Report Date: 09/25/2023
Date Signed: 09/25/2023 11:42:28 AM

Document Has Been Signed on 09/25/2023 11:42 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	DEWEY HOME INC.		FACILITY NUMBER:	198200623
ADMINISTRATOR:	RAFAEL BRAVO		FACILITY TYPE:	740
ADDRESS:	2127 DEWEY STREET		TELEPHONE:	(310) 458-8006
CITY:	SANTA MONICA	STATE: CA	ZIP CODE:	90405
CAPACITY:	6	CENSUS: 0	DATE:	09/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:46 AM
MET WITH:	Administrator Rafael Bravo		TIME COMPLETED:	12:00 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 09/25/2023 at 8:38 am, Licensing Program Analyst (LPA) David España conducted an unannounced required annual visit. Upon arriving at the facility, LPA met with the Administrator Rafael Bravo, who assisted with the visit. Upon arrival at the facility, LPA David España conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection. LPA observed all mandated inspection control posters were posted.LPA verified that the facility has an approved mitigation plan report. The facility is a Residential Care Facilities for the Elderly (RCFE) licensed for six (6) non- ambulatory clients. Currently, there are zero (0) non-ambulatory residents residing in the facility, all 60 or older. LPA and Administrator toured the physical plant. The facility is a one-story structure located in a residential neighborhood. It consists of the following: four (4) resident bedrooms, with three (3) bathrooms, living room, dining room, kitchen, outside laundry room. No weapons are stored in the premises.Kitchen was inspected and observed to be clean and operational. There were no bodies of water or obstructions on the premises. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational.LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Cleaning supplies and toxins, were stored in the laundry room and sharps objects are stored in locked kitchen drawers, locked and not accessible to clients. The kitchen was inspected and there is a 2-day supply of perishable and a 7-day supply of non-perishable food available, maintained properly. Two (2) fully charged fire extinguishers were kitchen and backyard. Outside grounds were toured, no bodies of water were observed. Walkways around the home were clear of hazards. Common areas were observed clean; all doorways were free of obstruction. LPA requested Administrator Rafael Bravo full staff file to be mail, fax, or e-mailed by 09/26/2023.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023

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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: DEWEY HOME INC.	FACILITY NUMBER: 198200623
	VISIT DATE: 09/25/2023

NARRATIVE

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The following Technical Assistance (1) and Technical Violations were noted during the today’s visit:
Technical Assistance:

Physical Plant/Environmental Safety - Technical Assistance: 87307(d)(7)

Technical Violations:

Resident Rights/Information - Technical Violation: 87468(c)(2)(A)
Disaster Preparedness - Technical Violation: 1569.695(a)(5)

No deficiencies cited. Exit interview conducted and a copy of this report was given at the time of visit, Administrator Rafael Bravo.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023

LIC809 (FAS) - (06/04)

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