198204848-2-11-2022-11-AS-PBUR-CBJLYL-20220211081031

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198204848
Report Date: 02/02/2022
Date Signed: 02/11/2022 08:10:56 AM

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:	PLD FAMILY HOME CARE		FACILITY NUMBER:	198204848
ADMINISTRATOR:	PRECIOUS DENNIS		FACILITY TYPE:	740
ADDRESS:	139 WEST ELLIS AVENUE		TELEPHONE:	(310) 419-5829
CITY:	INGLEWOOD	STATE: CA	ZIP CODE:	90302
CAPACITY:	6	CENSUS: 5	DATE:	02/02/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Precious Dennis		TIME COMPLETED:	12:00 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	Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced required 1- year visit with the primary focus on Infection Control measures and using the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA was properly screened for COVID-19 symptoms and temperature was checked. LPA Bunker met with Administrator Precious Dennis and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved mitigation plan report. LPA Bunker verified all current staff fingerprints cleared/associated with the facility. There are currently five (5), Residential Care Facility for the Elderly (RCFE) consumers in placement. The following Domain will be observed and reviewed: Infection Control Practices "I will be using this tool and methods that have been developed to improve the efficiency and accuracy of the Department of Social Services' facility inspections." The facility is a single-story home located in a residential neighborhood. LPA Bunker and Administrator Ms. Dennis toured the facility which consisted of the following: A living room, 4 bedrooms, 2 bathrooms, dining room, kitchen, laundry area, detached garage, shaded area, indoor/outdoor activity areas. Bedrooms #1-4, and bathrooms #1-2 are designated for the residents. See continued LIC809-C page #2

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022

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: PLD FAMILY HOME CARE	FACILITY NUMBER: 198204848
	VISIT DATE: 02/02/2022

NARRATIVE

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Continued LIC809-C page #2

Documents are posted as mandated. Bedrooms contain the furniture mandated, Bathrooms are clean and operational. Personal accommodations were observed for safety, privacy, and comfort, including grab bars, and non-skid surfaces mats. The kitchen was observed for the ability to prepare and serve food. The food service was reviewed for appropriate quantity and proper storage; there was an ample supply of perishable and nonperishable food. The resident’s medications were reviewed for proper storage, documentation, and system implementation. Medications are locked, and records are current. Common areas observed for the ability to safely serve the needs of the residents, including cleanliness, and clear of any potential hazards to the residents. The first aid kit is fully stocked with manual, smoke, and carbon monoxide detectors were in compliance, hot water temperature measured at 112 degrees Fahrenheit, fire extinguishers are fully charged, adequate linen supply, the facility telephones are working, residents call button, and motion sensors are operable. The Resident's bedroom windows have no sliding window locks with thumbscrews, all exit doors were in compliance, the yard was free of debris hazards, and trash cans were covered. The facility conducted a fire drill on December 31, 2021. Staff was given training on dependent adult and elder abuse reporting.

LPA Bunker will return later today to complete the annual visit.

There were no deficiencies cited.

Exit interview conducted.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022

LIC809 (FAS) - (06/04)

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