198320050-6-22-2021-11-AS-EBRN-C3DVNS-20210526163536

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320050
Report Date: 05/26/2021
Date Signed: 06/22/2021 10:34:58 AM

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
MONTEREY PARK, CA 91754

FACILITY NAME:	CHEZ ANNIE HOME CARE		FACILITY NUMBER:	198320050
ADMINISTRATOR:	GORDON, MELISSA B		FACILITY TYPE:	735
ADDRESS:	1929 W. 65TH PL		TELEPHONE:	(646) 983-1962
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90047
CAPACITY:	4	CENSUS: 0	DATE:	05/26/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:13 PM
MET WITH:	Hamidou Soumare, Administrator		TIME COMPLETED:	04:30 PM

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Licensing Program Analyst (LPA) Erik Brown made and unannounced inspection to this facility. The purpose of today’s visit was to conduct the Required Annual inspection. During today’s visit, LPA met with Hamidou Soumare, Administrator and explained the reason for the visit. The facility has a capacity of 4 clients. The facility currently has 0 clients in care.

Upon entry to the facility, LPA observed hand sanitizer, a visitor and temperature log, paper towels and a thermometer. The facility consists of 3 resident bedrooms, 2 resident bathrooms, dining area, kitchen, laundry area and a patio area in the backyard. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. The facility has one shared bedroom that has two beds. 2 of 3 bedrooms have emergency exits that lead to the facility’s backyard. 1 bedroom has a private bathroom. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew, water temperature measured at 115 degrees F in resident bathrooms. Common areas were clean and clear of hazards; doorways were free of obstructions. All exit doors have an auditory alarm. Water temperature measured at 130 degrees F*.

Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Facility has interconnected 2 in 1 smoke detectors/carbon monoxide detectors; located in bedrooms and hallways. Fire extinguisher was fully charged and operational, toxins and sharps were locked under the kitchen sink and inaccessible to potential clients. First aid kit was available. Outside grounds were toured and no bodies of water were observed. Patio furniture with umbrella was accessible. Exits/ Walkways around the home were free of debris and hazards.

Report continued on LIC809-C

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Erik Brown	TELEPHONE: (747) 230-2283
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CHEZ ANNIE HOME CARE	FACILITY NUMBER: 198320050
	VISIT DATE: 05/26/2021

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Advisory Note: LPA observed water temperature to be 130 degrees F. The facility does not currently have clients, however, LPA advised Administrator to lower the level of the water temperature to fall within the regulatory temperature of 105-120 degrees F. Administrator adjusted temperature on-site during the visit.

LPA also advised the Administrator to ensure that pertinent covid-postings are available inside the facility.

No deficiencies Cited. Exit Interview Conducted and a copy of this report was given.

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Erik Brown	TELEPHONE: (747) 230-2283
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021

LIC809 (FAS) - (06/04)

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