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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198200906
Report Date: 03/24/2023
Date Signed: 03/24/2023 02:06:32 PM

Document Has Been Signed on 03/24/2023 02:06 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:ALTIUS II ADULT RESIDENTIALFACILITY NUMBER:
198200906
ADMINISTRATOR:PEDRO PEREZFACILITY TYPE:
735
ADDRESS:3745 W. 157TH STREETTELEPHONE:
(310) 973-8249
CITY:LAWNDALESTATE: CAZIP CODE:
90260
CAPACITY: 6CENSUS: 4DATE:
03/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Maricela PachecoTIME COMPLETED:
02:30 PM
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On 03/24/23, Licensing Program Analyst (LPA) Wendy Gibbs conducted an unannounced required annual visit using the CARE Inspection Tools. Upon arrival at the facility, LPA met with House Manager, Maricela Pacheeco, and explained the purpose of today’s visit. Currently the facility has 4 residents. All residents were at their day program
Structure The facility is a single-story home in a residential neighborhood. The facility consists of 3 bedrooms, 1 and ½ bathrooms, living room, dining room, kitchen, office room and laundry area.
Physical Plant LPA and House Manager both toured the inside and outside grounds of the facility. In the living room a fireplace with a screen over the front. House manager stated they do not use it. In the backyard is a shaded outdoor area with a table and chairs. The front and backyard are maintained. All walkways are clean, clear, and free of obstructions, hazards, and debris. All gates on the side of the house open easily from the backyard. LPA did not observe any bodies of water on the premises.
Bedrooms LPA inspected all resident bedrooms. LPA observed they had the required furniture including bed, dresser, nightstand with lamp, chair available, and ample storage space. LPA observed all beds to have the required linens including a mattress cover, fitted sheets, blankets, comforter and pillow. All bedrooms had ample lighting. In Resident’s rooms are their games, toys and activities.
Bathrooms LPA inspected all bathrooms. LPA observed sufficient liquid soap, LPA was notified that client at facility has been diagnosed with PICA and facility prefers not to have paper towels in bathroom. Facility has plan to ensure clients are provided with paper towels when needed. Toilets and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. The water temperature measured at 106.3-degrees Fahrenheit in client bathroom.
Linens & Hygiene LPA observed an ample supply of towels, bed linens, blanket, comforters, and pillows in the cabinet in the hallway. LPA observed Residents personal hygiene products in a box in their room, extra supplies in the hall cupboard and additional supplies stored in the closet in the office.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2023
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: ALTIUS II ADULT RESIDENTIAL
FACILITY NUMBER: 198200906
VISIT DATE: 03/24/2023
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Kitchen LPA inspected the kitchen and observed a two-day supply of perishable and a seven-day supply of non-perishable food. LPA observed all cutleries, pot, and pans to be in good repair. All appliances were in good working repair. All knives and sharps are secured in a lock cabinet in the office. All toxins and cleaning supply were secured in a locked storage cabinet located in the laundry room. The water temperature in the kitchen measured 107.8-degrees Fahrenheit.
Common Rooms LPA toured all common rooms. The dining room has a long rectangular table and enough chairs to accommodate all residents. In the living room is a couch, 2 recliners and a chair to accommodate all residents. All walkways were clean, clear and free of hazards and obstructions. All rooms and hallways had ample lighting. A comfortable temperature was maintained in the facility.
Safety LPA observed a fully charged fire extinguisher mounted on the wall in the kitchen, with the receipt. All smoke detectors were tested and are fully operable. The carbon monoxide detector was tested and is operable. LPA observed a fully stocked First Aid Kit containing all required items and a manual. The last emergency drill was conducted on 01/11/23. LPA observed a working landline telephone. LPA observed all required documents posted. Due to residents taking posting off the walls they are posted in the laundry area next to the office.
Infection Control During the tour, LPA observed the facility’s infection control practices. LPA reviewed the Resident’s daily temperature log and Covid symptom log. LPA observed PPE supplies are readily available to staff, and an additional 60-day supply of PPE was stored in the closes in the office. Sufficient paper, cleaning, and disinfecting supplies were observed. LPA observed infection control posting at the front door and in the laundry area and bathrooms.
Medications Centrally stored medications were observed stored in their originally received containers and secured in a locked cabinet in the kitchen. LPA reviewed all Resident medications and matched them to the MARs.
Files LPA reviewed all resident files and found they contained the required documents. LPA reviewed 6 staff files and found they contained the required documents, training, and certification. LPA reviewed the training logs for all staff. LPA reviewed the P & I for the Residents. LPA reviewed the Surety Bond.
Interviews LPA interviewed House Manager. No other staff or Resident’s were present during the visit.

No deficiencies were cited during todays visit.

An exit interview was conducted and a copy of this report was provided to Maricela Pacheco.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023
LIC809 (FAS) - (06/04)
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