198203584-8-30-2022-11-AS-ASOO-CHSN6G-20220830101105

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198203584
Report Date: 08/28/2022
Date Signed: 08/30/2022 10:11:18 AM

Document Has Been Signed on 08/30/2022 10:11 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	AUNT MONA'S CARE HOME, INC.		FACILITY NUMBER:	198203584
ADMINISTRATOR:	MONA MCCALLISTER		FACILITY TYPE:	740
ADDRESS:	2522 SUNNYSIDE RIDGE RD.		TELEPHONE:	(310) 833-3131
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90275
CAPACITY:	6	CENSUS: 5	DATE:	08/28/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:26 PM
MET WITH:	Mona Mccallister, Administrator		TIME COMPLETED:	04:00 PM

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Licensing Program Analyst (LPA) Ana Soto conducted an unannounced Annual required and infection control visit to the above facility. LPA was met by Mona Mccallister, Administrator and the purpose of today’s visit was explained.

There are currently (5) residents in the facility. (1) residents are ambulatory, (2) are non-ambulatory, (2) bedridden. The facility is a single-story structure located in a residential neighborhood. It consists (6) bedrooms, (3) full bathrooms, Surveillance cameras system, ramp along side back of facility, laundry room/office, living room, fire place, dining room, shaded back yard with ramp on back porch, front yard and porch, and attached 2 car garage.

LPA and Mona toured the entire facility inside and out. Documents are posted as mandated. Bedrooms 1-6 are occupied by residents and contain the mandated furniture. The (3) bathrooms have grab bars and non-skid mats and are clean and operational. First aid kit is fully stocked with manual; smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to residents. Ample supply of perishable and nonperishable food, hot water temperature is between 105 -120 degrees Fahrenheit, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents, (3) fire extinguisher is fully charged. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in good repair.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2022

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: AUNT MONA'S CARE HOME, INC.	FACILITY NUMBER: 198203584
	VISIT DATE: 08/28/2022

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During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry & visitors and temperatures are logged and checked, sanitizer/soap, paper towels, in all the bathrooms and additional sanitation supplies are stored in the garage. LPA observed staff wearing masks, resident private rooms will be converted to isolation rooms (if needed.) Trash cans with lids, cart for PPE’s, mitigation plan posted and/or in folder, Fit testing not completed for staff, and required postings throughout the facility. Visitor designated area, facility has internet & Lap Top for residents to use, resident’s temperatures are checked and logged (once a day). Emergency contacts updated and posted; PPE's are enough for 30 days.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

Technical Advisory (TA) issued:

1. No fit testing completed for staff.

An exit interview was conducted with Mona MccAlister, Administrator and a hard copy of report was provided

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2022

LIC809 (FAS) - (06/04)

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