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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320037
Report Date: 01/13/2022
Date Signed: 01/13/2022 02:56:58 PM

Document Has Been Signed on 01/13/2022 02:56 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:CARMIE HOME CAREFACILITY NUMBER:
198320037
ADMINISTRATOR:RECIO, PAOLOFACILITY TYPE:
735
ADDRESS:14528/30 HALLDALE AVETELEPHONE:
(310) 938-2190
CITY:GARDENASTATE: CAZIP CODE:
90247
CAPACITY: 9CENSUS: 8DATE:
01/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:TIME COMPLETED:
03:00 PM
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On 1/13/22, Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA Called Administrator Paolo Recio to conduct the covid-19 screener questionnaire and was informed the facility is free of Covid-19. LPA was met by staff Rosauro de Guzman and explained the purpose of today’s visit is the annual visit concentrating on Infection control measure and was allowed entry into the facility. The facility is an ARF licensed for nine (9) ambulatory clients.

The facility is a one-story structure located in a residential neighborhood. It consists of the following: (4) resident bedrooms, (2) resident bathrooms, (1) staff bedroom, living room, dining room, kitchen, detached garage/storage, laundry room, and shaded outdoor seating area with table and chairs.

LPA and staff toured the physical plant. There were no bodies of water or obstructions on the premises. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed. 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.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Cleaning supplies and toxins, were stored in the laundry room and sharps objects are stored in under sink cabinet, locked and not accessible to clients. The kitchen was inspected and there is a 2-day supply of perishable and a 7-day supply of non-perishable food available, maintained properly. Two fully charged fire extinguishers were kitchen and backyard.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocol for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, a 30-day supply of Personal Protective Equipment (PPE) is available and sign in and out logs for visitors and staff are present in the facility.

No deficiencies were cited during visit.

Advisories are on attached 9102

An exit interview was conducted, and a copy of this report was provided to Paolo Recio Administrator.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2022
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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