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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198201272
Report Date: 02/03/2022
Date Signed: 02/11/2022 09:40:04 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:MANAGED CARE GUEST HOMEFACILITY NUMBER:
198201272
ADMINISTRATOR:NILD A. SMITHFACILITY TYPE:
740
ADDRESS:3354 CARDIFF AVETELEPHONE:
(310) 253-5095
CITY:LOS ANGELESSTATE: CAZIP CODE:
90034
CAPACITY:6CENSUS: 3DATE:
02/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Nilda Smith, LicenseeTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ana Soto and Jeremiah Randle conducted an unannounced Annual required and infection control visit to the above facility. LPA,s were met by Nilda Smith, Licensee and the purpose of today’s visit was explained.

There are currently (3) residents in the facility. (1) residents are ambulatory and (2) are non-ambulatory. The facility is a single story structure located in a residential neighborhood. It consists (6) bedrooms, (4) full bathrooms, shaded back yard, front yard, ramp on all exits, laundry room and attached 2 car garage.

LPA's and Nilda toured the entire facility inside and out. Documents are posted as mandated. Bedrooms 1-3 are occupied by residents and contain the mandated furniture. Bedroom 4 is vacant, Bedrooms 5&6 are staff bedrooms. The (2) bathrooms are clean and operational. Other 2 bathrooms are staff bathrooms. First aid kit is fully stocked without manual, smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to residents. Residents Medications do not have list. Resident and Staff file are current. Ample supply of perishable and nonperishable food, hot water temperature is 105 degrees Fahrenheit, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents, 1 fire extinguisher is fully charged. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in good repair. During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry, visitors are logged and temperature checked, sanitizer/soap in the staff bathroom and additional sanitation supplies are locked in the garage. LPA observed staff and residents wearing masks, resident private rooms will be converted to isolation rooms (if needed) and required postings throughout the facility. The residents temperature's are checked and logged once a day. PPE's are enough for 30 days.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did observe deficiencies, therefore citations were issued.

An exit interview conducted with Nilda Smith, Licensee and copy of report provided via email.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: MANAGED CARE GUEST HOME
FACILITY NUMBER: 198201272
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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87465 (a)(9)(A) - A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency. This was not met as evidence by based on Facility not having first aid manual. This poses a health and safety risk for residents.
POC Due Date: 02/17/2022
Plan of Correction
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Licensee to take picture of First aid manual and sent to LPA by email, text, or fax by POC due date.
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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4