198204848-1-18-2023-11-AS-MLEN-CN7RV9-20230118122110

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198204848
Report Date: 01/18/2023
Date Signed: 01/18/2023 12:30:52 PM

Document Has Been Signed on 01/18/2023 12:30 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:	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: 4	DATE:	01/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:36 AM
MET WITH:	Precious Dennis - Administrator		TIME COMPLETED:	12:45 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) Mario Leon conducted an unannounced required 1- year visit with the primary focus on Infection Control measures. Upon arrival at the facility, LPA Leon was met by Semira Bushura and later by Administrator Precious Dennis. LPA was properly screened for COVID-19 symptoms and temperature was checked. LPA met with Administrator Precious Dennis and explained the purpose of today's Annual Inspection. There are currently four (4), Residential Care Facility for the Elderly (RCFE) consumers in placement. The facility is a single-story home located in a residential neighborhood. LPA Leon and Administrator Ms. Dennis toured the facility which consisted of the following: A living room, four (4) bedrooms, two (2) bathrooms, one (1) half-bathroom, 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. LPA and administrator toured the physical plant. There are no bodies of water or firearms/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. 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 106.8 F in the kitchen and 105 F in bathroom one (1). A comfortable temperature is maintained in the facility, at 77.1 F. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is enough perishable and non-perishable food available which is stored properly. Fire extinguishers were charged, smoke detectors and Carbon Monoxide were operable. See LIC809-C

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

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: PLD FAMILY HOME CARE	FACILITY NUMBER: 198204848
	VISIT DATE: 01/18/2023

NARRATIVE

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During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations ( Located in common areas and restrooms). LPA observed staff were wearing face coverings, an isolation room and required postings were throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

During today’s visit there was one deficiency observed, see LIC809-D.

Exit interview held. A copy of the report was provided to Precious Dennis.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/18/2023 12:30 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: PLD FAMILY HOME CARE	FACILITY NUMBER: 198204848
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(29)

General Food Service Requirements

(b) The following food service requirements shall apply: (29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on Licensing Program Analyst's observation, the licensee did not comply with the section cited above in which the burners do not light internally by the included knobs, the burners are to be lit by an external lighter which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/27/2023
	Plan of Correction
1 2 3 4	Administrator Precious Dennis and LPA have agreed to having the stove properly repaired/replaced prior to the POC due date. Adminstrator will submit video evidence of the repair or replacement prior to the POC due date to both Felisa.Shirley@dss.ca.gov and/or Mario.Leon@dss.ca.gov

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: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

LIC809 (FAS) - (06/04)

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