198202438-8-7-2023-11-AS-WGIS-CUGKZL-20230807082056

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198202438
Report Date: 08/04/2023
Date Signed: 08/07/2023 08:21:03 AM

Document Has Been Signed on 08/07/2023 08:21 AM - 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:	218TH STREET HOUSE (HFL HARBOR GATEWAY HOMES)		FACILITY NUMBER:	198202438
ADMINISTRATOR:	LIESS, CAROL		FACILITY TYPE:	735
ADDRESS:	1418 W. 218TH STREET		TELEPHONE:	(310) 781-9489
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90501
CAPACITY: 6		CENSUS: 5	DATE:	08/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Meliza Bumanlag		TIME COMPLETED:	05:00 PM

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On 8/04/2023, Licensing Program Analyst (LPA) Wendy Gibbs and Ruby Velasco conducted an unannounced required annual visit using the CARE Inspection Tools. LPAs met with House Manager, Meliza Bumanlag, and explained the purpose of today’s visit. The facility serves adults aged 18-59, ambulatory only. The facility is licensed for six (6) ambulatory adults. During time of visit there were 5 residents present.

Structure The facility is a single-story home in a residential neighborhood. The home consists of 4 client bedrooms, 2 bathrooms, living room, dining room, kitchen, office, and staff room.

Physical Plant LPAs toured the facility with House Manager. The front and backyard were landscaped and clean. The backyard has a shaded patio area with a table and chairs. All walkways were clean, clear, and free of obstructions, hazards, or debris. The gates on the side of the home open quickly and easily for exiting. No bodies of water were observed on the premises.

Bedrooms LPAs inspected the bedrooms and found the walls and floors to be in good repair. All rooms had the required furniture, including a bed(s), dresser(s), nightstand(s) with lamp(s), chair(s), and ample closet space for residents to store their belongings. LPAs observed the required linens on all beds, including a mattress cover, fitted sheets, blanket, comforter, and pillows. LPAs observed an ample supply of linens stored in the cupboard in the hallway. All bedrooms were observed to have ample lighting.

Bathrooms LPAs inspected both bathrooms and found they meet Title 22 regulations. Both bathrooms were observed to have fully functioning toilets, sinks, and showers. All showers were clean and free of mold or mildew. All showers had non-skid material, secured safety handrails, and shower chairs available. LPAs observed an ample supply of toiletries in a cabinet in the bathroom and an additional supply in a cupboard in the hallway. LPAs observed an ample supply of towels, wash clothes, and hand towels stored in a cabinet in the hallway. The water temperature measured 105.0-degrees and 118.0-degrees Fahrenheit.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023

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: 218TH STREET HOUSE (HFL HARBOR GATEWAY HOMES)	FACILITY NUMBER: 198202438
	VISIT DATE: 08/04/2023

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Kitchen LPA inspected the kitchen. LPAs observed an ample supply of cutleries, pots, and pans. All appliances were observed to be in good working repair, including stove burners, oven, refrigerator, and dishwasher. LPAs observed a 3-day supply of perishable foods and a 7-day supply of non-perishable foods. All sharps and knives are secured in a locked drawer in the kitchen. All cleaning supplies are secured in a locked closet in the hallway. The water temperature measured 120-degrees Fahrenheit.

Common Rooms The living room has two (2) couches to accommodate all clients comfortably. LPAs observed a screened fireplace, House Manager stated the fireplace is not used. On the fireplace, LPAs observed puzzles and games available for clients. The dining room has a large rectangular and 8 chairs to accommodate all clients. LPAs observed an ample supply of water stored in a cabinet in the dining room. All rooms had ample lighting. All hallways and walkways were observed clean, clear, and free of hazards or obstructions. The facility was maintained at a comfortable temperature. All rooms had ample lighting.

Safety LPAs observed two (2) fully charged fire extinguishers last serviced on 01/27/23. The last emergency drill was conducted on 07/31/23. LPAs inspected the First Aid Kit and observed it had the required items and a manual. All emergency documents and phone numbers were posted. There is a working landline telephone in the facility.

Infection Control LPAs observed a sanitizing station at the entrance of the facility with visitor logs and temperature logs. LPAs observed staff wearing face masks. LPAs observed a 30-day supply of PPEs. LPAs observed required Infection Control signs posted throughout the facility.

Medications LPAs observed all Centrally Stored Medications secured in a locked cabinet in the dining room. All medications were observed in their original containers. LPAs reviewed the Medication Administration Record (MAR) and medications. Three out of three resident’s MARs and medication are consistent with properly documented records.

Files & Interviews LPAs reviewed three (3) client files and observed they contained the required documents. LPAs interviewed five (5) clients, five out of five stated they were happy here and their needs are met. LPAs reviewed three (3) staff files and observed they contained the required documents, training, and certification. LPAs interviewed one (1) staff who was present at the facility, and they were able to explain policy, procedures, and personal rights of clients. LPAs reviewed the facility Surety Bond and staff training logs done monthly. LPAs observed all required signs posted throughout the facility.

No deficiencies were cited during today’s visit.

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

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023

LIC809 (FAS) - (06/04)

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