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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320037
Report Date: 01/17/2023
Date Signed: 01/17/2023 11:06:15 AM

Document Has Been Signed on 01/17/2023 11:06 AM - 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: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: 7DATE:
01/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:57 AM
MET WITH:Rosauro DeGuzmanTIME COMPLETED:
11:30 AM
NARRATIVE
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On 1/17/23, Licensing Program Analyst (LPA) Mario Leon conducted an unannounced annual required visit with a primary focus on Infection Control measures. LPA was met by Caregiver Rosauro DeGuzman and explained the purpose of today’s visit. 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. One fire extinguisher was located in kitchen.

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) was not available and sign in and out logs for visitors and staff are present in the facility.

Two (2) deficiencies were cited during visit, see LIC-809D

Advisories are attached, see LIC 9102

An exit interview was conducted, and a copy of this report was provided to Caregiver Rosauro DeGuzman.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2023
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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Document Has Been Signed on 01/17/2023 11:06 AM - It Cannot Be Edited


Created By: Mario Leon On 01/17/2023 at 10:27 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CARMIE HOME CARE
FACILITY NUMBER: 198320037

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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
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Based on Licensing Program Analyst's (LPA) Mario Leon's observation, the licensee did not comply with the section cited above in which LPA observed fire extinguisher's guage, located in kitchen, was marked as "needs to be recharged" which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/20/2023
Plan of Correction
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Caregiver Rosauro DeGuzman will have Administrator Paolo Recio have the fire extinguisher recharged or replaced before this coming Friday, 01/20/2023 and will submit photo evidence of the new unit via email.
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on Licensing Program Analyst's (LPA) Mario Leon's observation, the licensee did not comply with the section cited above in which LPA observed lysol below bathroom one (1) sink which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/17/2023
Plan of Correction
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Caregiver Rosauro DeGuzman immediately moved and locked away the cleaning solutions while LPA was on-site.
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
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2023


LIC809 (FAS) - (06/04)
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