198320093-6-27-2023-11-AS-AINZ-CT7U76-20230627151925

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320093
Report Date: 06/27/2023
Date Signed: 06/27/2023 03:19:31 PM

Document Has Been Signed on 06/27/2023 03:19 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:	GARDENIA HOME		FACILITY NUMBER:	198320093
ADMINISTRATOR:	MARTIN, LATIESHA		FACILITY TYPE:	735
ADDRESS:	510 WEST 169TH STREET		TELEPHONE:	(832) 991-1938
CITY:	GARDENA	STATE: CA	ZIP CODE:	90248
CAPACITY: 4		CENSUS: 3	DATE:	06/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:13 PM
MET WITH:	Lavida Hart/Designate Administrator		TIME COMPLETED:	03:19 PM

NARRATIVE

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On 6/27/2023 Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Lavida Hart /Designated Administrator and the purpose of today’s visit was explained. The facility is licensed to operate for (4) non-ambulatory developmentally disabled or Mentally Ill adults ages 18 through 59. Currently, the home has (3) ambulatory and (0) non-ambulatory client. The clients are from: Westside Regional Center. (2) clients have Restricted Health Care Conditions, and (0) are utilizing postural supports or protective devices.

The facility is a single-story home located in a residential neighborhood. The facility consists of the following: four (4) resident bedrooms, one (1) bathroom, living room, dining room, kitchen, and back patios with shaded areas as well as attached garage.

LPA Iniguez and staff 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. 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 105.6F°, Bathroom #1 116.8°F).

Evaluation Report continues LIC 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023

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: GARDENIA HOME	FACILITY NUMBER: 198320093
	VISIT DATE: 06/27/2023

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Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide/Smoke detectors combo were observed and operational. Fire extinguishers were fully charged, toxins and knifes were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Last facility fire drill was 5/23/2023.

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. A copy of Surety Bond will be email to LPA together with proof of association from S#2.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8.

See D pages for Citations.

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Lavida Hart/Designate Administrator.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/27/2023 03:19 PM - It Cannot Be Edited

Created By: Alfonso Iniguez On 06/27/2023 at 03:01 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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GARDENIA HOME	FACILITY NUMBER: 198320093
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80066(a)(10)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review the licensee did not comply with the section cited above in not having the LIC 503 form health screening which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/10/2023
	Plan of Correction
1 2 3 4	Licensee will ensure LIC 503 is in staff files at all time. Licensee will gather S#2 LIC 503 form and send a copy to LPA via email before POC due date.

Type B

Section Cited

CCR

80066(a)(11)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in having a CPR card for S#2 on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/10/2023
	Plan of Correction
1 2 3 4	Licensee will ensure TB test are in staff files at all times. Licensee will gather S#2 TB test and send a copy via email to LPA 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: 06/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023

LIC809 (FAS) - (06/04)

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