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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320090
Report Date: 02/02/2024
Date Signed: 02/02/2024 02:14:58 PM

Document Has Been Signed on 02/02/2024 02:14 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:SOUTH BAY FAMILY HOME, LLCFACILITY NUMBER:
198320090
ADMINISTRATOR:CHAVEZ, KARENFACILITY TYPE:
735
ADDRESS:21821 ARCHIBALD AVE.TELEPHONE:
(310) 919-8272
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 4CENSUS: 2DATE:
02/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:31 AM
MET WITH:Karen Chavez/AdministratorTIME COMPLETED:
02:15 PM
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On 2/2/2024 Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Karen Chavez /Administrator and the purpose of today’s visit was explained. The facility is licensed to operate for (3) developmentally disabled or Mentally Ill adults ages 18-59 of which (4) may be ambulatory and (2) non-ambulatory in room #3. Currently, the home has (2) clients. The clients are from: Harbor Regional Center. (1) clients have Restricted Health Care Conditions, and (1) are utilizing postural supports or protective devices. The staff to client ration: 1-2.

The facility is a one-story structure located in a residential neighborhood. It consists of the following: three (3) bedrooms (one currently used by live-in staff), two (2) client bedrooms, one (1) bathroom, living area, dining area, kitchen, outdoor area with table, chairs, and umbrella.

LPA Iniguez and administrator toured the inside and outside of the facility. All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting was observed, plenty of dresser and closet space was observed. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. 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 properly measured between 105F°-120F° degrees (Kitchen 110.5F°, Bathroom #1 108.5°F).

Evaluation Report continues LIC 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: SOUTH BAY FAMILY HOME, LLC
FACILITY NUMBER: 198320090
VISIT DATE: 02/02/2024
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LPA Iniguez observed the facility to be clean, sanitary, and appropriately furnished at the time of the visit. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. Carbon monoxide/Smoke detectors were observed and operational. Fire extinguishers were fully charged, toxins were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last facility disaster drill was:1/15/2024.

LPA conducted a records review of (2) client records, (2) staff records and reviewed the facility disaster plan. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (2) Client Medication Administration Records (MAR) and did not observe any discrepancies at the time of visit.

LPA notified administrator about the facility annual fees not been current, a total of $1,135.00 is due on 2/5/24. LPA provided PIN: 515383 to administrator.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See below for deficiencies:

-No Medical assessment and TB test in C#1’s file.

-No recent TB test on file for C#2.


An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Ann McKenzie/Staff.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024
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Document Has Been Signed on 02/02/2024 02:14 PM - It Cannot Be Edited


Created By: Alfonso Iniguez On 02/02/2024 at 02:04 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: SOUTH BAY FAMILY HOME, LLC
FACILITY NUMBER: 198320090

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(b)(1)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment. (1) Such assessment shall be performed by a licensed physician, or designee, who is also a licensed professional, and the assessment shall not be more than one year old when obtained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interviews, and records review, the licensee did not comply with the section cited above in not having a medical assesment for C#1on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/20/2024
Plan of Correction
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Administrator will ensure all clients have a medical assesment on file. As Plan of Correction(POC) administartor will submit to LPA a copy of C#1's medical assesment via email before POC due date.
Type B
Section Cited
CCR
80069(c)(1)
Client Medical Assessments
(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interviews, and records review, the licensee did not comply with the section cited above in not having a TB test for C#1 and a current TB test for C#2 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/20/2024
Plan of Correction
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Administrator will ensure all clients have a current TB test on file. As Plan of Correction(POC) administartor will submit to LPA a copy of C#1 and C#2 TB tests via email before POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Eva M Alvarez
LICENSING EVALUATOR NAME:Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2024


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