198204012-10-21-2023-11-AS-DESA-CWTQUG-20231021122844

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198204012
Report Date: 10/21/2023
Date Signed: 10/21/2023 12:28:52 PM

Document Has Been Signed on 10/21/2023 12:28 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:	ATKINSON CARE HOME		FACILITY NUMBER:	198204012
ADMINISTRATOR:	MUQEET D. DADABHOY		FACILITY TYPE:	740
ADDRESS:	17035 ATKINSON AVENUE		TELEPHONE:	(310) 819-8218
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90504
CAPACITY:	6	CENSUS: 4	DATE:	10/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Licensee, Muqueet “MD” Dadahboy		TIME COMPLETED:	12:50 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 10/21/2023 at 8:45 am Licensing Program Analyst (LPA) David España conducted an unannounced 1-year Annual visit to the facility. Upon arriving at the facility, LPA met with Licensee Muqueet “MD” Dadahboy, who assisted with the visit. The purpose of today’s visit was discussed. Upon arrival at the facility, LPA conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection. LPA was granted access and allowed to enter the facility to conduct inspections. LPA and Licensee toured the physical plant. The facility is located in a residential area. During today’s visit, LPA observed the following: The Residential Care Facilities for the Elderly (RCFE) facility is licensed to operate for six (6) non-ambulatory residents age 60 and above of which six (6) can be hospice residents. The facility is two-story structure located in a residential neighborhood. It consists of the following: four (4) resident rooms, two (2) resident bathrooms, one (1) living area, one (1) dining area, one (1) kitchen, and one (1) outside patio area including two (2) shed for storage and one (1) table with four (4) chairs with shade. The second story of the facility is not accessible to residents and consists of one (1) office space with one (1) restroom and one (1) staff rest/break room with a restroom. There is a total of two (2) refrigerators and two (2) freezers, and the washer and dryer are located in the detached garage also used for storage. There were no bodies of water or obstructions on the premises. There are ramps leading to the backyard for each resident room to exit the front yard. The front yard consists of a white gate separating the sidewalk and the property and a small waterfall on the left side of the house in the corner. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting 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 between 105.0 F to 120.0 F (i.e., 114.5 F) in the bathrooms and kitchen sink.A comfortable temperature was maintained in the facility. Evaluation Report Continues on LIC 809-C

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2023

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: ATKINSON CARE HOME	FACILITY NUMBER: 198204012
	VISIT DATE: 10/21/2023

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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 nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days were observed. Freezers and refrigerators are maintaining temperatures. Medication is labeled and inaccessible to clients in dining room cabinet.

There is a fully charged fire extinguisher in the kitchen, smoke detectors and carbon monoxide were operable. Medications were stored in a locked cabinet in the kitchen. During the visit, LPA observed the facility infection control practices. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

All mandated inspection control posters were posted.

No deficiencies were cited during this inspection visit.

However, one (1) technical violation and one (1) technical assistance were issued.

Technical Violation
Staffing - Technical Violation: 1569.618(c)(3)

Technical Assistance
Resident Rights/Information - Technical Assistance: 87468(c)(2)(A) -

An exit interview was conducted, and a copy of this report and appeals rights was provided to Licensee, Muqueet “MD” Dadahboy.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2023

LIC809 (FAS) - (06/04)

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