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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320034
Report Date: 07/14/2021
Date Signed: 07/19/2021 03:05:23 PM

Document Has Been Signed on 07/19/2021 03:05 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME:CN HOME #5FACILITY NUMBER:
198320034
ADMINISTRATOR:MATHARU, PRITAMFACILITY TYPE:
735
ADDRESS:2207 ARLINGTON AVETELEPHONE:
(310) 612-0978
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 4CENSUS: 3DATE:
07/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:CATHERINE LEDESMATIME COMPLETED:
01:30 PM
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On 7/14/2021 at 11:00 am, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA Montoya called Administrator Catherine Ledesma and conducted a risk assessment over the telephone. Based on the assessment, the facility is clear of Covid-19 infection. LPA verified that the facility has an approved mitigation plan report.

The facility is licensed to serve four (4) non-ambulatory clients, ages 18-59, developmentally disabled. LPA observed three (3) clients present during today's visit and two (2) clients are over 60 years of age. LPA verified that the facility has already submitted age exceptions prior to this visit. The facility's annual fees are current.

LPA toured the single-story facility with Administrator Ledesma. The facility consists of four (4) bedrooms, four (4) bathrooms, a dining area, a living room, an office, and an activity room.

During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance. PPE supplies are readily available to staff, and an additional 30-day supply of PPE is stored in the activity room; sufficient paper, cleaning, and disinfecting supplies were observed. The facility’s designated visitation area is the client's own bedroom and the front patio. LPA observed staff and residents maintain 6 feet physical distancing. All three on-duty staff are wearing a mask.

All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed.

There are no security bars or weapons on the premises. Resident bathrooms were checked, sufficient liquid soap was observed. Toilets and water faucets worked properly, grab bars were secure, the shower was free of mold/mildew, and a non-skid mat was in place. A comfortable temperature was maintained in the facility.

Continued report in LIC 809C

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2021
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
MONTERY PARK, CA 91754
FACILITY NAME: CN HOME #5
FACILITY NUMBER: 198320034
VISIT DATE: 07/14/2021
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LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in a locked cabinet. Centrally stored medications are stored in their originally received containers and kept safe and locked and inaccessible to clients in care. The First Aid kit was available. One fire extinguisher last serviced on 6/24/2021 was observed in the hallway near the bedrooms.

Outside grounds were toured, and no bodies of water were observed. Walkways around the home were clear of hazards. Common areas were clean and clear of hazards; doorways were free of obstructions.

LPA reviewed the facility’s surveillance testing records and vaccination records. All nine (9) staff and three (3) clients are fully vaccinated. Covid-19 Infection Control and Prevention training records and in-service training on the approved mitigation plan were reviewed. An emergency contact list was reviewed.

No deficiency was cited during today's visit.

Exit interview conducted, and a copy of this report was provided to Administrator Catherine Ledesma.

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
LIC809 (FAS) - (06/04)
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