198204800-11-14-2023-11-AS-FSHY-CXBSC6-20231106124503

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198204800
Report Date: 11/06/2023
Date Signed: 11/14/2023 01:57:22 PM

Document Has Been Signed on 11/14/2023 01:57 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:	MY MOTHER'S PLACE		FACILITY NUMBER:	198204800
ADMINISTRATOR:	HILDA LOZANO		FACILITY TYPE:	740
ADDRESS:	11827 ROSE AVENUE		TELEPHONE:	(310) 707-7768
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90066
CAPACITY:	6	CENSUS: 4	DATE:	11/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:31 AM
MET WITH:	Hilda Lozano, Administrator		TIME COMPLETED:	12:50 PM

NARRATIVE

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On 11/6/2021, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced Annual required visit to My Mother’s Place Facility. LPA was met by Licensee Hilda Lozano and the purpose of today’s visit was explained.

The facility is licensed for six non-ambulatory residents, and currently houses four (4) residents. LPA toured the facility with Hilda Lozano, Administrator, including but not limited to the kitchen, a total of six bedrooms in the home, 5 for residents, and 1 personal . LPA inspected the laundry area, garage, and backyard area. LPA observed the facility to be free of odor, clean and in good repair.

LPA and Hilda toured the physical plant. All rooms were inspected. Beds and bedding supplies were present, and adequate lighting was provided. The kitchen was inspected and there is perishable and non-perishable food available. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly. Shower was free of mold/mildew, adequate lighting, and sufficient toiletries accessible to clients. Water temperature properly measured between 105*-120F* (119.5*).

Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. Fire extinguishers were charged, smoke detectors and carbon monoxide were operable.

LPA and Hilda toured the backyard and LPA observed that there is a shaded area present. There were no bodies of water present. LPA observed a storage room located behind garage with food, supplies and PPE.

LPA reviewed Medication Records and observed them to be maintained in order and accurate.

cont'd on 809-C

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

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: MY MOTHER'S PLACE	FACILITY NUMBER: 198204800
	VISIT DATE: 11/06/2023

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LPA found that the oven is not operational and licensee did not have staff’s Cardiopulmonary resuscitation, (CPR) cards readily available.

Deficiencies are being cited based on LPA observations and interviews conducted in accordance with the California Code of Regulations, Title 22, Divisions 6 chapter 1, see LIC 809D.

An exit interview was conducted, Plans of Corrections were discussed and a copy of this report and appeals rights were and left with Administrator Hilda Lozano whose signature on this form confirms receipt of these documents.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/14/2023 01:57 PM - It Cannot Be Edited

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: MY MOTHER'S PLACE	FACILITY NUMBER: 198204800
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

80087

Buildings and Safety (a) the facility shall be clean safe, snitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in which the stove in the facility does not work which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/20/2023
	Plan of Correction
1 2 3 4	Scheduled repairman on Wednesday 11/8/23

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: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 11/14/2023 01:57 PM - It Cannot Be Edited

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: MY MOTHER'S PLACE	FACILITY NUMBER: 198204800
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on obervation and interview, the licensee did not comply with the section cited above in which the licensee did not ensure that staff is certified and trained in CPR which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/20/2023
	Plan of Correction
1 2 3 4	Licensee will have a service to come to train and certify all staff with CPR certification.

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: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

LIC809 (FAS) - (06/04)

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