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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320037
Report Date: 01/17/2025
Date Signed: 01/17/2025 10:57:06 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/17/2025 10:57 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:CARMIE HOME CAREFACILITY NUMBER:
198320037
ADMINISTRATOR/
DIRECTOR:		RECIO, PAOLOFACILITY TYPE:
735
ADDRESS:14528/30 HALLDALE AVETELEPHONE:
(310) 938-2190
CITY:GARDENASTATE: CAZIP CODE:
90247
CAPACITY: 9CENSUS: 7DATE:
01/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Paolo Recio, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
NARRATIVE
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On 01/27/25, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced required annual visit using the full CAREs Inspection Tool. LPA met with Administrator, Paolo Recio and explained the purpose of today’s visit. The facility is licensed to serve elderly developmentally disabled residents ages 18 thru 59 years old.

LPA reviewed all resident files and found that they contained all required documents. LPA reviewed three (2) staff files and found they did not contain all required documents. During file review, LPA did not observe the surety bond.

LPA Felisa and Paolo toured both inside and outside of the facility. The facility is a one-story structure located in a residential neighborhood. The facility consists of (4) client bedrooms, (1) staff bedroom, (2) bathrooms, living room, kitchen, dining area, and patio. Facility maintains all required posting throughout the facility.

All bedrooms were toured. Bedrooms 1-4 are occupied by residents and contain the mandated furniture. LPA observed all rooms to have the required furniture including a bed and chair(s). All beds had the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillow. LPA observed ample lighting in all the bedrooms.

LPA Shirley and Paolo toured the kitchen and found it to be clean and sanitary. All appliances were in good working order. Knives were locked and stored. The medications were locked and stored in the file cabinet located in the living room. LPA observed a 3-day supply of perishable and a 7-day supply of nonperishable foods. The water temperature measured at 119.1.


Con'd
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2025
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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: CARMIE HOME CARE
FACILITY NUMBER: 198320037
VISIT DATE: 01/17/2025
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The (2) bathrooms are clean and operational. First aid kit is fully stocked with manual. No firearms are stored at facility and no bodies of water present.

LPA Shirley and Paolo walked through all common areas. In the living room, kitchen, dining room there is ample seating and space for all residents. All rooms and walkways were clean, and clear of obstructions and hazards. All areas have ample lighting. All rooms, hallway, and living room have working smoke detectors. There is a charged fire extinguisher in the kitchen. The backyard is clean and clear of obstructions and hazards, and there are no bodies of water present.

One (1) deficiency was cited during visit, see LIC-809-D.



An exit interview was conducted, and a copy of this report and appeals rights was provided to House Manager/Caregiver, Rosauro DeGuzman .
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/17/2025 10:57 AM - It Cannot Be Edited


Created By: Felisa Shirley On 01/17/2025 at 10:38 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: CARMIE HOME CARE
FACILITY NUMBER: 198320037

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2025
Section Cited
CCR
80025(b)

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80025 Bonding

(b) All licensees, other than governmental entities, who are entrusted to care for and control clients' cash resources shall file or have on file with the licensing agency, a bond issued by a surety company to the State of California as principal.

This requirement is not met as evidenced by:
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Administrator must proide copy of Surety Bond to CCLD via fax or email by POC due date of 1/31/25. Proof of Corrections can be emailed to felisa.shirley@dss.ca.gov or fax to 424-544-1016.
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Based on interview and records reviewed, the facility's Administrator did not obtain a surety Bond which poses a potentional personal rights risk to persons in care.
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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
LICENSING EVALUATOR NAME:Felisa Shirley
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2025


LIC809 (FAS) - (06/04)
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