198203270-10-27-2023-11-AS-WGIS-CWZUK7-20231027153841

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198203270
Report Date: 10/27/2023
Date Signed: 10/27/2023 03:38:46 PM

Document Has Been Signed on 10/27/2023 03:38 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	HI-HOPES, INC.		FACILITY NUMBER:	198203270
ADMINISTRATOR:	HAI NGUYEN		FACILITY TYPE:	735
ADDRESS:	16204 DAPHNE AVENUE		TELEPHONE:	(310) 323-8874
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90504
CAPACITY: 6		CENSUS: 4	DATE:	10/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:36 PM
MET WITH:	Melonie Suarlez		TIME COMPLETED:	04:00 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 10/27/23, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced annual visit to the facility listed above. LPA met with Direct Support Professional (DSP), Marissa Paule, and explained the purpose of today's visit. We were later joined by Administrator, Melonie Suarlez. The facility serves developmentally disabled clients ages 18-59 and is approved for 4 ambulatory and 2 non-ambulatory. There was one client present during time of visit. Physical Plant/Structure The facility is a single-story home in a residential neighborhood. The home consists of the following 6 bedrooms (4 Client rooms, Office, Supply room), 3 bathrooms, activity room/office, living room, kitchen, dining room, shaded area, outdoor activity area, laundry room and an attached garage. All walkways outside were observed clean, clear, and free of debris, hazards, and obstructions. LPA did not observe any bodies of water on the premises. Bedrooms LPA inspected all bedrooms and found them to be clean and in good repair. All client bedrooms had the required furniture, including a bed, dresser, nightstand, chair, and ample storage space for Client's personal belongings. All beds were observed with the required linens including a mattress cover, fitted sheets, blanket, comforter and pillows. All bedding was observed to be in good repair. LPA observed an ample supply of bed linens in a cabinet in the hallway. All bedrooms had ample lighting. Bathrooms LPA inspected all bathrooms and found them to be within Tittle 22 regulations. All bathrooms were observed clean and operational. LPA observed showers had nonskid mats, shower chairs available, and secured safety hand rails. LPA observed and ample supply of towels, wash cloths and hygiene products in a closet in the bathroom. The water temperature measured 110.6-degrees Fahrenheit. Kitchen LPA inspected the kitchen and found it to be clean and sanitary. LPA observed all appliances to be operational and in good repair. LPA observed an ample supply of cutleries, pots, and pans in good repair. LPA observed a 3-day supply of perishable and a 7-day supply of non-perishable foods. All foods were observed properly stored and labeled. Sharps are secured in a locked cabinet in the laundry room. Cleaning supplies are secured in a locked cabinet under the kitchen sink. The water temperature measured 118.3-degrees Fahrenheit.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023

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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HI-HOPES, INC.	FACILITY NUMBER: 198203270
	VISIT DATE: 10/27/2023

NARRATIVE

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Common Rooms LPA inspected all common rooms and found them to be clean and in good repair. The activity room has a counter and cabinets with games, activities, and crafts. The dining room has a long rectangular and benches to accommodate all clients. The living room has two couches to accommodate all clients. LPA observed a screened fireplace that is inaccessible to clients. All rooms were observed with ample lighting. All walkways and hallways were observed clean, clear, and free of obstructions and hazards. The facility was maintained at a comfortable temperature.
Files & Interviews LPA reviewed all resident files and found they contained the required documents. LPA was unable to conduct client interview due to clients being at day program. LPA reviewed the Client's P&I funds and logs. LPA reviewed the facilities Surety Bond through National Mutual Insurance Company. LPA reviewed Administrator and staff files and found they contained the the required documents, training, and certification. LPA interviewed two staff and they were able to explain policy, procedure, and Client rights.
Medications All Centrally Stored Medications are secured in a locked cabinet in the activity room and are inaccessible to residents. LPA reviewed the medications and MARs for two Clients and found they were consistent with properly documented records.
Safety LPA observed a fully charged fire extinguisher last serviced on 03/20/23. The last fire inspections form the local fire department was conducted on 03/20/23. Smoke and carbon monoxide detectors are in compliance and are operational. The last emergency drill was conducted on 10/09/23. LPA inspected the First Aid kit and found it contained the required items and a manual. Gate on the side open easily to exit and is accessible to clients. The facility has a landline telephone. LPA observed all required postings throughout the facility.
Infection Control LPA observed all required infection control signs posted throughout the facility. LPA observed sanitizing stations in the bathrooms and living room. LPA observed a 30-day supply of PPE's stored in the staff room and garage.

According to the California Code of Regulations (Tittle 22, Division 6, Chapter 8) LPA did not observe or cite any deficiencies.
An exit interview was conducted with Administrator, Melonie Suarez, and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023

LIC809 (FAS) - (06/04)

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