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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320038
Report Date: 02/18/2022
Date Signed: 02/18/2022 03:14:33 PM


Document Has Been Signed on 02/18/2022 03:14 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 CARE IIFACILITY NUMBER:
198320038
ADMINISTRATOR:RECIO, ANGELOFACILITY TYPE:
740
ADDRESS:14532/34 HALLDALE AVETELEPHONE:
(424) 292-3136
CITY:GARDENASTATE: CAZIP CODE:
90247
CAPACITY:6CENSUS: 5DATE:
02/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Albert SimonTIME COMPLETED:
03:31 PM
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On 2/1822, 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 spoke with Administrator Angelo Recio to conduct the covid-19 screener questionnaire and was informed the facility is free of Covid-19. LPA was met by staff 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 Residential Care Facility for the Elderly (RCFE) ages 60 and above. The requested capacity is six (6), non-ambulatory, bedridden clients. There is currently five (5) residents in placement.

The facility is a single story, 4 client bedroom, 1 staff bedroom and 2 bathrooms home located in a residential neighborhood. The facility has a living room, office area, dining area, kitchen, laundry area outside in the backyard in a shed, detached garage, shaded area, indoor/outdoor activity areas.

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. 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 fully charged fire extinguishers was found in kitchen.

During the visit, LPA observed the facility infection control practices. 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.

Due to time constraints, visit will be completed at a later date.

There were no deficiencies cited or technical advisories given during this visit

An exit interview was conducted, and a copy of this report was provided to Albert Simon
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2022
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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