198320046-3-14-2024-11-AS-PSCT-D3CSX6-20240314141525

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320046
Report Date: 03/14/2024
Date Signed: 03/14/2024 02:15:29 PM

Document Has Been Signed on 03/14/2024 02:15 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	DROCK HOME CARE		FACILITY NUMBER:	198320046
ADMINISTRATOR:	ADAMSON RUKAYAT		FACILITY TYPE:	740
ADDRESS:	1652 E CYRENE DRIVE		TELEPHONE:	(310) 997-8046
CITY:	CARSON	STATE: CA	ZIP CODE:	90746
CAPACITY:	6	CENSUS: 5	DATE:	03/14/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:21 AM
MET WITH:	Rukayat Adamson		TIME COMPLETED:	03:00 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 03/14/24, at 11:30am, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced visit to DROCK HOME CARE. The purpose of today’s visit was to conduct the required annual inspection, using the new Care Tool. LPA was met by licensee, Rukayat Adamson, and the purpose of today’s visit was explained. The facility is licensed to serve residents aged 60 and over; six (6) ambulatories of which 6 may be non-ambulatory and a hospice waiver for 4. Currently, the home has (5) non-ambulatory residents. None of the residents have Restricted Health Care Conditions and none utilizes postural supports or protective devices. The facilities’ annual fees are current.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: 3 resident bedrooms, 2 staff bedrooms, 1 resident bathroom, 1 staff bathroom, living room, dining room, kitchen, attached two car garage, and back yard patio with table and six chairs.

LPA conducted a records review of (5) resident records, (2) staff records, and reviewed the facility disaster plan. All resident & staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (4) resident Medication Administration Records and did not observe any discrepancies at the time of visit.

At 11:50am, LPA and the Licensee toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All resident rooms were checked. Beds and bedding were in good condition, adequate lighting provided, adequate storage for resident personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations. Toilets and water faucets worked properly. The shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature measured 107.9F. A comfortable temperature is maintained in the facility.

Report continued on LIC809-C

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (707) 849-2315
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: DROCK HOME CARE	FACILITY NUMBER: 198320046
	VISIT DATE: 03/14/2024

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
26
27
28
29
30
31
32

LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is enough perishable and non-perishable food available, which is stored properly. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked with manual. The fire extinguisher was charged, and smoke/carbon Monoxide detectors were operable. The last fire/emergency drill was conducted on 01/20/2024.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents. LPA observed that sanitizing stations were in common areas and restrooms. LPA observed that the facility had the required postings, posted throughout the facility. LPA further observed the facility to have a 90-day supply of Personal Protective Equipment (PPE).

LPA advised the administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing (www.cdss.ca.gov) for Provider Informational Notices (PIN) and for any updates relating to COVID-19 guidance and other related issues.

No deficiencies were cited during this inspection visit.

An exit interview was conducted, and a copy of this report was provided to Licensee, Rukayat Adamson.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (707) 849-2315
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2