198320043-11-8-2022-11-AS-PBUR-CKYUKN-20221108143925

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320043
Report Date: 10/26/2022
Date Signed: 11/08/2022 02:39:49 PM

Document Has Been Signed on 11/08/2022 02:39 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:	HEARTLAND ADULT RESIDENTIAL FACILITY		FACILITY NUMBER:	198320043
ADMINISTRATOR:	LOTANAKA SMILEY-WILLIAMS		FACILITY TYPE:	735
ADDRESS:	1847 W 75TH STREET		TELEPHONE:	(323) 753-4440
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90047
CAPACITY:	5	CENSUS: 3	DATE:	10/26/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Nicole Williams		TIME COMPLETED:	03:45 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	Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced required 1- Year visit with the primary focus on Infection Control measures and using the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA was properly screened for COVID-19 symptoms and temperature was checked. LPA Bunker met Nicole Williams and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved mitigation plan report. There are currently three (3) clients in placement. The following Domain will be observed and reviewed: Infection Control Practices "I will be using this tool and methods that have been developed to improve the efficiency and accuracy of the Department of Social Services facility inspections." The facility is a single-family home located in a residential neighborhood. Licensee Ms. Williams and LPA Bunker toured the facility which consisted of the following: Living room, kitchen, dining room, 3 bedrooms, 3 bathrooms, laundry room, locked medication cabinet in the kitchen, shaded area, and indoor/outdoor activity areas. The front and back yard landscape is in good condition at the time of the visit. During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance; hand sanitizer, thermometer, and PPE supplies are readily available to staff. Sufficient paper, cleaning, and disinfecting supplies were observed. Ms. Williams indicates that the administrator reviews the PINS and is up to date on the PINs. See continued LIC809-C on page 2

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

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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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: HEARTLAND ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 198320043
	VISIT DATE: 10/26/2022

NARRATIVE

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Continued LIC809-C page 2

Documents are posted as mandated. Bedrooms contain the furniture mandated, Bathrooms are clean and operational. Personal accommodations were observed for safety, privacy, comfort, and non-skid surface mats. The kitchen was observed for its ability to prepare and serve food. The food service was reviewed for appropriate quantity and proper storage; there was an ample supply of perishable and nonperishable food. The resident’s medications were reviewed for proper storage, documentation, and system implementation. Medications are locked, and records are current. Common areas were observed for the ability to safely serve the needs of the residents, including cleanliness, and clearness of any potential hazards to the residents. The first aid kit is fully stocked with manual, smoke, and carbon monoxide detectors were in compliance, the hot water temperature was measured at 115 degrees Fahrenheit within the normal limits (105-120F degrees), the fire extinguisher is fully charged, adequate linen supply, the facility telephones are working, and there are no firearms on the premises. The client's bedroom windows have no sliding window lock with thumbscrews, all exit doors were in compliance, hazardous items are inaccessible to clients, the yard was free of debris hazards, and trash cans were covered. Staff was given training on dependent adult and elder abuse reporting. The facility fire/emergency drill was conducted on October 06, 2022.

There were no deficiencies cited.

Exit interview conducted.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

LIC809 (FAS) - (06/04)

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