198202431-8-31-2023-11-AS-WGIS-CV92B9-20230831171447

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198202431
Report Date: 08/31/2023
Date Signed: 08/31/2023 05:14:51 PM

Document Has Been Signed on 08/31/2023 05:14 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:	223RD STREET HOUSE (HFL HARBOR GATEWAY HOMES)		FACILITY NUMBER:	198202431
ADMINISTRATOR:	LIESS, CAROL M		FACILITY TYPE:	735
ADDRESS:	1435 W. 223RD STREET		TELEPHONE:	(310) 781-9094
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90501
CAPACITY: 6		CENSUS: 6	DATE:	08/31/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Edna Dulay		TIME COMPLETED:	04:35 PM

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On 08/31/23, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced annual visit at the facility listed above. During today's visit, LPA met with House Manager, Edna Dulay, and explained the purpose of today's visit. The facility is licensed for 6 ambulatory clients who are mentally disabled. There are currently 6 clients residing in the home and 5 were present during the visit.

Structure The facility is a two-story home in a residential neighborhood. The facility consists of 3-client bedrooms, 3-bathrooms, staff office, staff room, living room, kitchen, dining room, and attached garage.

Physical Plant During today’s visit, LPA and House Manager toured the facility and the grounds. The front and back yard were observed to be clean and maintained. In the backyard, LPA observed shaded sitting areas available for client use. All walkways were clean, clear, and free of obstructions, debris, and hazards. The gate on the side of the house easily opens to exit. LPA did not observe any bodies of water.
Bedrooms LPA inspected all resident bedrooms and observed them to be clean and well maintained. All bedrooms had the required furniture including a beds, dressers, chairs, nightstands, and ample closet space for client’s personal belongings. All beds were observed to have the required linens including mattress cover, fitted sheets, blankets, comforter, and pillows. LPA observed an ample supply of bed linens, blankets, and comforters.
Bathrooms LPA inspected all bathrooms and found them to be within Title 22 regulations. All bathrooms were observed to be clean, sanitary, and operational. All showers were free of mold and mildew. All showers had nonskid mats and secured safety handrails. The water temperature measured 113.9-degrees, 118.1-degress, and 118.4-degrees Fahrenheit. LPA observed an ample supply of towels, wash cloths, and toiletries available for clients.
Kitchen LPA inspected the kitchen and found it to be clean and sanitary. LPA observed all appliances to be in good working repair, including the stove, oven, dishwasher, microwave, and refrigerator. LPA observed an ample supply of cutleries, pots, and pans.

Report Continued on LIC9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

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: 223RD STREET HOUSE (HFL HARBOR GATEWAY HOMES)	FACILITY NUMBER: 198202431
	VISIT DATE: 08/31/2023

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LPA observed a 3-day supply of perishable foods and a 7-day supply of nonperishable foods. All foods were observed to be properly stored and labeled. LPA observed a menu posted on a cork board in the dining room. The sharps are stored in a locked drawer in the kitchen. The cleaning supplies are secured in a locked cupboard under the sink in the kitchen and an additional supply are secured in a locked cabinet in the garage. The water temperature measured 105.6-degrees Fahrenheit.
Common Rooms LPA inspected all common rooms. The living room has ample seating to accommodate all clients. LPA observed games in the living room. The dining room has a large rectangular table and 6 chairs to accommodate all clients. LPA observed an ample supply of games, activities, and crafts stored in a cabinet in the garage. All hallway and stairs were observed to be clean, clear, and free of obstructions and hazards. The facility was maintained at a comfortable temperature. All rooms were observed to have adequate lighting.
Safety LPA observed multiple fully charged fire extinguisher last serviced on 01/27/23. Smoke detectors were observed in all rooms, that are interconnected and hard wired, and are operational. The last emergency drill was conducted on 07/31/23. All exits are clearly marked. The facility has a working landline telephone. LPA observed all required CCL postings throughout the facility. LPA inspected the First Aid Kit and found it contained the required items.
Medications LPA reviewed the medications and medication administration record (MAR) for three clients. LPA observed the medications in their original packaging. The medication count is consistent with the MARs. Medications are secured in locked cabinet in the locked staff office and are inaccessible to clients.
File Review & Interviews LPA reviewed three client files and found the contained the required documents. LPA interviewed 4 clients who were present during the visit. All clients stated they are happy with their care and the staff at the facility. LPA reviewed the Administrator, and 2 staff files and found they contained the required certification, training, and documents. LPA interviewed staff that was at the facility, and they were able to answer questions regarding personal rights, care, policy, and procedure. LPA reviewed the facility Surety Bond and Clients P & I.
Infection control Before entry, LPA called to do a risk assessment and the facility is free of Covid. Upon entry LPAs temperature was taken and logged. LPA observed a sanitizing station and sign in log at the entrance of the facility. LPA observed a 60-day supply of PPEs, stored in a cabinet in the garage. LPA observed required infection control signs posted throughout the facility.

No deficiencies were observed or cited during today’s visit.

An exit interview was conducted with House Manager, Edna Dulay, and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

LIC809 (FAS) - (06/04)

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