198201272-2-14-2023-11-AS-AALR-CP2RNW-20230214121100

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198201272
Report Date: 02/14/2023
Date Signed: 02/14/2023 12:11:05 PM

Document Has Been Signed on 02/14/2023 12:11 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	MANAGED CARE GUEST HOME		FACILITY NUMBER:	198201272
ADMINISTRATOR:	NILD A. SMITH		FACILITY TYPE:	740
ADDRESS:	3354 CARDIFF AVE		TELEPHONE:	(310) 253-5095
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90034
CAPACITY:	6	CENSUS: 3	DATE:	02/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:49 AM
MET WITH:	Caregiver, Molato Marygrace		TIME COMPLETED:	12:20 PM

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Licensing Program Analyst (LPA) Antonia Alvizar conducted an unannounced Annual required and infection control visit to the above facility. LPA was met by Caregivers Marygrace Molato, Ronald Molato and the purpose of today’s visit was explained.There are currently (3) residents in the facility. (3) residents are ambulatory and (0) are non-ambulatory. The facility is a single-story structure located in a residential neighborhood. It consists (7) bedrooms, (2) full bathrooms, shaded back yard, front yard, ramp on all exits, laundry room and attached car garage.

LPA and Marygrace toured the entire facility inside and out. Documents are posted as mandated. Bedrooms #2, #3 and #4 are occupied by residents and contain the mandated furniture. Bedrooms #1, #2 and #6 is vacant, Bedroom #7 is staff bedroom. The two (2) bathrooms are clean and operational. 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. Medications are stored, locked and inaccessible to residents. 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. 3 fire extinguishers where fully charged mounted on dining room, hallway and garage walls.

Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 115.5 Fahrenheit in bathroom #2, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents. A comfortable temperature is maintained in the facility.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: MANAGED CARE GUEST HOME	FACILITY NUMBER: 198201272
	VISIT DATE: 02/14/2023

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Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. No bodies of water present and 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 wearing masks, resident private rooms will be converted to isolation rooms (if needed) and required postings throughout the facility. The resident’s temperatures are checked and logged once a day.

LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). Marygrace provided LPA a copy of facility Liability Insurance.

LPA advised the Caregivers to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Division - Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did observe deficiencies, therefore citations were not issued.

An exit interview conducted with Marygrace Molato, Caregiver and copy of report was provided

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023

LIC809 (FAS) - (06/04)

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