198300069-7-11-2024-11-AS-DESA-D73QLN-20240711121612

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198300069
Report Date: 07/11/2024
Date Signed: 07/11/2024 12:16:21 PM

Document Has Been Signed on 07/11/2024 12:16 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	MONROE CARE SOLUTIONS		FACILITY NUMBER:	198300069
ADMINISTRATOR:	MONROE, CARLISS		FACILITY TYPE:	735
ADDRESS:	1442 WEST VERNON AVE		TELEPHONE:	(323) 309-5399
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90062
CAPACITY:	6	CENSUS: 6	DATE:	07/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:06 AM
MET WITH:	Staff 3		TIME COMPLETED:	01:00 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	On 07/11/24, at 8:06 am Licensing Program Analyst (LPA), David España conducted an unannounced annual visit using the full CAREs tool. Upon arrival at the facility, LPA España conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection. LPA verified that the facility has an approved mitigation plan report. LPA was granted access and allowed to enter the facility to conduct the inspection. LPA España was met by Staff 3 and the purpose of today’s visit was explained. The Adult Residential Facility serves Developmentally Disabled Adults for ages 18 to 59 years. The requested capacity is for 6 clients, 6 ambulatory. Facility has a fire clearance for 6 ambulatory clients only. Facility is a 3-client bedroom, 2- bathroom, 1 one-story house with an outdoor shaded area in the back yard. The client bedrooms are spacious and easily accommodate the client's furnishings. There is a back yard which contains a table and 6 chairs as well as a large tree for shade. Outdoor passageways, walkways, driveways, steps, and patios are free from obstructions. LPA did not observe hazards, such as ladders, gardening tools and/or motorized equipment in the front, back and/or side areas of the facility. All three bedrooms have two beds, two chairs, overhead lighting, closets, and dressers. All drawers comply with the requirement of 8 cubic feet of space. There were no designated staff bedrooms observed. Bathrooms have working toilets, wash basins and shower/bathtub. Continued on 809-C

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024

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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Document Has Been Signed on 07/11/2024 12:16 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: MONROE CARE SOLUTIONS	FACILITY NUMBER: 198300069
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary 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, interview and record review, the licensee did not comply with the section cited above. LPA observed the kitchen exhaust fan does, not operate when switched on. No audible noise or visible movement of blades observed, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/11/2024
	Plan of Correction
1 2 3 4	According to Title 22 regulations, the facility administrator needs to develop and submit a comprehensive plan of correction to the department, detailing how the identified violation will be addressed within the specified timeframe. Administrator to email LPA at david.espana@dss.ca.gov by 8/11/2024.

Type B

Section Cited

CCR

80087(a)(1)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above. LPA observed A black trash bin was observed to be broken from the bottom. This damage compromises the bin's integrity and functionality, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/18/2024
	Plan of Correction
1 2 3 4	According to Title 22 regulations, the facility administrator needs to develop and submit a comprehensive plan of correction to the department, detailing how the identified violation will be addressed within the specified timeframe. Administrator to email LPA at david.espana@dss.ca.gov by 7/18/2024.

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: David Espana	TELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/11/2024 12:16 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: MONROE CARE SOLUTIONS	FACILITY NUMBER: 198300069
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80066(a)(10)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above. LPA observed there was no health screening form filled out and signed by a physician, which is a direct violation of Section 80065(g) (10). 2. Tuberculosis Test Documents: The required tuberculosis test documentation, as specified in Section 80065(g) (11), was also absent for staff 3, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/18/2024
	Plan of Correction
1 2 3 4	According to Title 22 regulations, the facility administrator needs to develop and submit a comprehensive plan of correction to the department, detailing how the identified violation will be addressed within the specified timeframe. Administrator to email LPA at david.espana@dss.ca.gov by 7/18/2024.

Type B

Section Cited

CCR

85068.3(a)

Modifications to Needs and Services Plan

(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review- the licensee did not comply with the section cited above. LPA observed that the Needs and Services Plans were absent for all clients, which include Client 1, Client 2, Client 3, Client 4, Client 5, and client 6, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/18/2024
	Plan of Correction
1 2 3 4	According to Title 22 regulations, the facility administrator needs to develop and submit a comprehensive plan of correction to the department, detailing how the identified violation will be addressed within the specified timeframe. Administrator to email LPA at david.espana@dss.ca.gov by 7/18/2024.

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: David Espana	TELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024

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: MONROE CARE SOLUTIONS	FACILITY NUMBER: 198300069
	VISIT DATE: 07/11/2024

NARRATIVE

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Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen; sheets, pillowcases, hand towels, bath towels and wash clothes where observed stored in each bedroom. The telephone system has a land line which was called by LPA and is operational. Emergency Disaster Plan and "See something, Say something, Let Us Know" posted & readily available for review on hallway wall. Two fully charged fire extinguishers were found in the facility, two mounted in bedroom hallways and one in the laundry area next to the kitchen. Dishes, cups, and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in a locked cabinet under kitchen sink. Food supply was adequately stored in kitchen refrigerator and cabinets and consists of the following: A variety of fresh and canned fruit, vegetable, and meat food items.
4 smoke detector and one carbon monoxide detector are present in the facility. All were tested and are fully operational. Oven, microwave, dish washer, washer, and dryer working. There are two refrigerators in the kitchen. Refrigerator and freezer are at the correct temperature for food storage. The residence is equipped with portable heaters and air conditioners. Locked/stored in the cupboard in hallway.
Area for medication storage and records was inspected, they are kept in a locked file cabinet. First aid kit, located in a locked cupboard from the kitchen area, was inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze. First aid and medications are available for staff use but inaccessible to clients. Continued 809-C

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024

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: MONROE CARE SOLUTIONS	FACILITY NUMBER: 198300069
	VISIT DATE: 07/11/2024

NARRATIVE

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LPA did not observe any pet or bodies of water at the facility.

Fire Clearance was approved on 4/12/2022 for 6 ambulatory clients with no special instructions. LPA did not observe pad locks or other mechanisms which may be obstructions for safe and quick egress during an emergency on side gates and front exits.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, there were deficiencies cited during this visit. There was 1 technical assistance provided in today’s visit.

Personnel Records - Training - Type B: 80066(a)(10)

Client Records - Incident Reports - Type B: 85068.3(a)

Disaster Preparedness - Technical Assistance: 1565(a)

Physical Plant & Environmental Safety - Type B: 80087(a)

Physical Plant & Environmental Safety - Type B: 80087(a)(1)

Exit visit. Copy of report signed and given to Staff 3.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024

LIC809 (FAS) - (06/04)

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