198200792-2-17-2023-11-AS-FSHY-CP5SYJ-20230217131733

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198200792
Report Date: 02/17/2023
Date Signed: 02/17/2023 01:17:44 PM

Document Has Been Signed on 02/17/2023 01:17 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:	EPI CENTER		FACILITY NUMBER:	198200792
ADMINISTRATOR:	DYE, MORGAN		FACILITY TYPE:	775
ADDRESS:	3926 W. 139TH STREET		TELEPHONE:	(310) 978-1254
CITY:	HAWTHORNE	STATE: CA	ZIP CODE:	90250
CAPACITY: 25		CENSUS: 13	DATE:	02/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:59 AM
MET WITH:	Morgan Dye		TIME COMPLETED:	01:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Felisa Shirley and Licensing Program Manager (LPM) Stephanie Cifuentes conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA Shirley and LPM Cifuentes met with Director, Morgan Dye. The purpose of today’s visit was discussed, and LPA and LPM were allowed access to the facility grounds. The facility is licensed to serve 25 developmentally disabled clients ages 18, years and above. Facility approved for 15 non-ambulatory and 10 ambulatory clients.

LPA, LPM and Director Dye all toured the grounds of the facility. Facility is located in a single-story building, located in a commercial business area. LPA observed that the facility includes: a large multipurpose room, 2 restrooms, a changing room, relaxation room, music room, art room, storage room, two (2) staff offices, and one (1) Program director office, kitchen, and an indoor/ outdoor activity area. Documents are posted as mandated by Title 22 Regulations. Bathrooms are clean and operational. Toilets and water faucets worked properly; grab bars were secure, comfortable temperature was maintained in the facility.

All clients bring their own lunch. Hazardous items are inaccessible to clients and kept in a storage cabinet. First aid kit is fully stocked. Medications are centrally stored in a locked cabinet in the Program Director office. LPA observed three (3) fully charged fire extinguishers which were inspected.

LPA toured the kitchen area and observed refrigerator and on site washer/dryer.

During the visit, LPA and LPM observed infection control practices. LPA Shirley observed a sanitizing station at the facility entry with visitors logs and temperature checks. Sanitizer/soap, paper towels are in all the bathrooms and additional sanitation supplies are stored in staff office. LPA observed staff wearing masks and was shown isolation area. LPA observed trash cans with lids and required postings are throughout the facility. Emergency contacts updated and posted; PPE's are enough for 30 days.

Con' d on 809-C.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023

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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Document Has Been Signed on 02/17/2023 01:17 PM - It Cannot Be Edited

Created By: Felisa Shirley On 02/17/2023 at 12:43 PM

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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: EPI CENTER	FACILITY NUMBER: 198200792
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

82088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA Shirley observed the water temperature to be 135.4F and 136.4F which poses an immediate health and safety risk to persons in care.
	POC Due Date: 02/21/2023
	Plan of Correction
1 2 3 4	Program Director will monitor water temperature for 24 hrs., and send documentation of change in temperature to CCLD via fax or email by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Stephanie Cifuentes

LICENSING EVALUATOR NAME:

Felisa Shirley

LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: EPI CENTER	FACILITY NUMBER: 198200792
	VISIT DATE: 02/17/2023

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No bodies of water were observed. Walkways were clear of hazards. Common areas were clean and clear of hazards; doorways were free of obstructions.

The following deficiencies were cited according to the California Code of Regulations, Title 22, Division 6, Chapter 3:

-LPA Shirley found the water temperature in bathroom #2 and kitchen to be 135.4F and 136.4F.

An exit interview was conducted and a copy of this report and appeal rights was provided to Morgan Dye.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023

LIC809 (FAS) - (06/04)

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