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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320068
Report Date: 06/09/2023
Date Signed: 06/09/2023 12:19:26 PM


Document Has Been Signed on 06/09/2023 12:19 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:CN HOME #6FACILITY NUMBER:
198320068
ADMINISTRATOR:TORRES, MAE MAUREEN A.FACILITY TYPE:
735
ADDRESS:1724 W 240TH STREETTELEPHONE:
(310) 326-6219
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY:6CENSUS: 4DATE:
06/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:26 AM
MET WITH:Mae Maureen TorresTIME COMPLETED:
12:35 PM
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On 06/09/2023, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced annual required visit using the new CARE Inspection Tool. LPA met with administrator, Mae Maureen Torres, and explained the purpose of today’s visit. The facility is licensed to operate for six (6) developmentally disabled adult clients between the ages of 18 through 59. The facility is approved for 6 non-ambulatory clients. Currently, the home has (4) clients. The clients are Harbor Regional Center clients. Three (3) of the clients have Restricted Health Care Conditions and none are utilizing 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: five (5) client rooms, two (2) bathrooms, an office, living area, dining area, kitchen, and an activities area. There is an outside shaded area in the backyard with an umbrella and ample seating. The laundry area is in a locked walk-in closet near the kitchen. The garage is attached to the home with access only through the front of the garage. The garage is used for storage only.

LPA conducted a records review of (4) client records, (8) staff records, (4) clients Personal & Incidental Records and reviewed the facility disaster plan. All client & Staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (4) Client Medication Administration Records and did not observe any discrepancies at the time of visit.

LPA and the administrator toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. 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. The water temperature met Title 22 standards in the bathrooms and kitchen sink and measured 110.8 F to 115.1 F. A comfortable temperature was maintained in the facility.

Evaluation Report Continues on LIC 809-C

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2023
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: CN HOME #6
FACILITY NUMBER: 198320068
VISIT DATE: 06/09/2023
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LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharp objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly. There is one (1) fire extinguisher fully charge located near the front door entrance. Smoke and carbon monoxide detectors were operable and in working condition. The last fire/emergency drill was conducted on 04/10/2023. LPA observed that the facility had a current first aid manual along with a first aid kit.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations (Located in common areas and restrooms). LPA observed staff were wearing face coverings, and the required postings were posted throughout the facility. LPA observed the facility has a 60-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.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview was conducted, and a copy of this report was provided to Administrator, Mae Maureen Torres.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2023
LIC809 (FAS) - (06/04)
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