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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204800
Report Date: 11/13/2024
Date Signed: 11/13/2024 10:52:25 AM

Document Has Been Signed on 11/13/2024 10:52 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:MY MOTHER'S PLACEFACILITY NUMBER:
198204800
ADMINISTRATOR/
DIRECTOR:		HILDA LOZANOFACILITY TYPE:
740
ADDRESS:11827 ROSE AVENUETELEPHONE:
(310) 707-7768
CITY:LOS ANGELESSTATE: CAZIP CODE:
90066
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 3DATE:
11/13/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:46 AM
MET WITH:Hilda LozanoTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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On 11/13/24, Licensing Program Analysts (LPA) Perry Scott conducted an unannounced POC visit. LPA Scott met with Hilda Lozano, Administrator. LPA Scott, informed Hilda Lozano that the purpose of today's visit was to ensure that the deficiencies cited during the annual inspection visit on 11/07/24 were corrected and in compliance with Title 22 Regulations.

LPA Scott observed that the following deficiencies were corrected:

87412(a) Personnel Records
LPA did not have access to personnel records during the annual inspection.

LPA Scott observed all records and did not find any deficiencies.

87465(a)(6) Incidental Medical and Dental Care
LPA did not have access to resident records.

LPA Scott observed all Medication Administration Records and did not find any deficiencies.

87506(b) Resident Records
LPA did not have access to resident records during the annual inspection.

LPA Scott observed all resident records and did not find any deficiencies.

HSC 1569.695(e) Emergency Plans A facility shall have all of the following information readily available to facility staff during an emergency: Emergency and Disaster Plan

Report Continued on LIC 809-C
Janae HammondTELEPHONE: (424) 544-1027
Perry ScottTELEPHONE: (707) 849-2315
DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2024
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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: MY MOTHER'S PLACE
FACILITY NUMBER: 198204800
VISIT DATE: 11/13/2024
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LPA Scott observed the Emergency and Disaster Plan and did not find any deficiencies.

HSC 1569.695(e)(1) (e) A facility shall have all of the following information readily available to facility staff during an emergency: (1) A resident roster with the date of birth for each resident.

LPA Scott observed the Resident Roster and did not find any deficiencies.

HSC 1569.695(e)(3) (e) A facility shall have all of the following information readily available to facility staff during an emergency: (3) A resident medication list for residents with centrally stored medications.

LPA Scott observed the Resident Medication Roster list and did not find any deficiencies.


LPA Scott provided Letters of Deficiency Citations Cleared.

No deficiencies observed during this visit.

An exit interview was conducted, and a copy of this Facility Evaluation Report was given to Hilda Lozano, Administrator.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: (707) 849-2315
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024
LIC809 (FAS) - (06/04)
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