<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198202562
Report Date: 11/20/2022
Date Signed: 11/20/2022 12:38:46 PM

Document Has Been Signed on 11/20/2022 12:38 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:MEDING'S HOME CARE IIFACILITY NUMBER:
198202562
ADMINISTRATOR:ROGELIO S. ROMEROFACILITY TYPE:
735
ADDRESS:123 WEST 220TH STREETTELEPHONE:
(310) 830-3286
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 6CENSUS: 3DATE:
11/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Rogelio Romero TIME COMPLETED:
12:47 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11/20/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA met with Administrator Rogelio Romero and explained the purpose of today’s visit. The facility is licensed to operate for four (4) ambulatory ages 18 through 59. The clients are Harbor Regional Center consumers.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: three (3) bedrooms of which (2) are used for clients and one (1) is for live-in staff, two (2) bathrooms one for (1) clients and the other one (1) is for staff, a living area, dining area, kitchen, and outside patio area.

LPA and administrator toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 109.0 F. A comfortable temperature of 74 degrees was maintained in the facility.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. A fire extinguisher was charged, smoke detectors and carbon monoxide were operable. A landline telephone was connected and working. The last Fire Drill was conducted on 11/05/22. The facility has a current liability insurance effective: 05/12/22 - 05/12/23.

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2022
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 3
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: MEDING'S HOME CARE II
FACILITY NUMBER: 198202562
VISIT DATE: 11/20/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
INFECTION CONTROL:
During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff and client's vaccination records was conducted. The facility has a Mitigation Plan Report approved by CCLD

DEFICIENCY:
During record review of service files, LPA identified client #2 - #3 (C2-C3) both are over 60 years of age. The is a violation of Title 22 Regulations Section 85068.4 Acceptance and Retention Limitations.

Deficiency is cited on LIC 809-D.

An exit interview was conducted and a copy of this report was provided to Rogelio Romero.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/20/2022 12:38 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 11/20/2022 at 12:24 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: MEDING'S HOME CARE II
FACILITY NUMBER: 198202562

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.4(c)(1-5)
85068.4 Acceptance and Retention Limitations (c) When a licensee admits or retains any person 60 years of age or older, the licensee shall ensure that all of the following information is contained in the person's file: 1) Completed Functional Capabilities Assessment, required by Section 80069.2...

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
This requirement was not met as evidenced by: Based on LPA’s observation, interview and record review, Client #2 (C2) over 60 years old. The facility does not have approved age exception for the client. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2022
Plan of Correction
1
2
3
4
The Licensee/Administrator shall review the Title 22 Section 85068.4 regulations and comply. The administrator shall send a request for age exceptions for clients 60 years of age and over by the POC due date: 12/12/22.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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 Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2022


LIC809 (FAS) - (06/04)
Page: 3 of 3