198320038-2-22-2023-11-AS-WGIS-CPB2WE-20230222164525

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320038
Report Date: 02/22/2023
Date Signed: 02/22/2023 04:45:30 PM

Document Has Been Signed on 02/22/2023 04:45 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	CARMIE HOME CARE II		FACILITY NUMBER:	198320038
ADMINISTRATOR:	RECIO, ANGELO		FACILITY TYPE:	740
ADDRESS:	14532/34 HALLDALE AVE		TELEPHONE:	(424) 292-3136
CITY:	GARDENA	STATE: CA	ZIP CODE:	90247
CAPACITY:	6	CENSUS: 5	DATE:	02/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:31 PM
MET WITH:	Rosemarie Famisan		TIME COMPLETED:	04:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 2/22/23, Licensing Program Analyst (LPA) Wendy Gibbs conducted an unannounced annual required visit with a primary focus on Infection Control measures. LPA was met with House Manager, Rosemarie Famisan, and explained the purpose of today’s visit. The facility is Residential Care Facility for the Elderly (RCFE) ages 60 and above. The capacity is six (6), non-ambulatory, bedridden clients. There are currently five (5) residents in placement. Structure The facility is a single-story home in a residential neighborhood. It consists of four (4) resident bedrooms, one (1) staff room, two (2) bathrooms, living room, dining room, office area, and kitchen. Physical Plant LPA and House Manager toured the facility inside and out. In the back there is a table with chairs and umbrella. The laundry area is on the side of the facility, covered and inaccessible to residents. Within the laundry area is a locked cabinet with an additional supply of cleaning supplies. There is a detached garage. There are no bodies of water on the premises. The outside area was clean and clear of hazards, obstructions, and debris. Bedrooms All bedrooms were inspected. LPA observed the required furniture in all rooms, including bed(s), nightstand(s) with a lamp, dresser(s), and chair(s). There was ample storage space for resident’s personal belongings. Beds and bedding supplies were in good condition, all beds had the required linens including mattress cover, fitted sheets, blanket, comforter and pillow. All rooms had ample lighting. Bathrooms Bathrooms were found to be within Title 22 regulations and were clean and operational. All showers had a nonskid mat and a shower chair. Both bathrooms had ample lighting. The water temperature measured between 106.8-degrees and 107.1-degrees Fahrenheit. Linens & Hygiene LPA observed an ample supply of bed linens, comforter and towels stored in a cupboard in the hallway. LPA observed an ample supply of hygiene products stored for residents.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CARMIE HOME CARE II	FACILITY NUMBER: 198320038
	VISIT DATE: 02/22/2023

NARRATIVE

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Kitchen LPA and House Manager inspected the kitchen. All appliances were clean and in good working condition. All cutleries, pots and pans were in good repair. All sharps are in a locked drawer and inaccessible to residents. LPA observed a 3-day supply of perishable foods and a 7-day supply of nonperishable foods. All food were stored and labeled properly. All cleaning supply and toxins are securely stored under the kitchen sink and inaccessible to residents. The water temperature measured 107.8-degrees Fahrenheit.
Common Rooms LPA inspected all common rooms. LPA observed seating available for all resident’s and visitors. LPA observed activities in the living room for residents. The dining room has a large table and enough chairs to accommodate all residents. All walkways were clean, clear and free of obstructions and hazards. There is ample lighting in all rooms and walkways. LPA observed the facility to be sanitary and appropriately furnished at the time of visit.
Safety LPA observed two (2) fully charged fire extinguisher, one in the kitchen and the other in the dining room. They were last serviced on 08/24/22. All smoke detectors were fully functioning. The carbon monoxide detector was operational. The last emergency drill was on 01/28/23. All exits were clearly marked. The facility sketch was posted throughout the facility. LPA observed a fully stocked First Aid Kit with the manual. All required postings were posted throughout the facility. The facility has a working landline telephone.
Infection Control During the visit, LPA observed the facility infection control practices. LPA observed staff were wearing face coverings. LPA observed a 30-day supply of Personal Protective Equipment (PPE). There is a sign-in log and temperature log for visitors, staff and residents. LPA observed PPE carts made up and ready. All required infection control signs were posted throughout the facility. LPA observed sanitizing stations throughout the facility.
Medications LPA reviewed all resident medications and the MARs. Medications are securely stored in a cabinet in the staff area and are inaccessible to residents.
Files LPA reviewed all five (5) resident files and found they contained the required documentation. LPA reviewed two (2) of the Staff files and found they contained the required documentation, certification and training.

LPA reviewed the facilities Liability Insurance through Acord, which expires on 08/01/23.

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 Rosemarie Famisan.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023

LIC809 (FAS) - (06/04)

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