198320095-11-12-2020-11-AS-JCAS-BVAPFM-20201112101658

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320095
Report Date: 10/30/2020
Date Signed: 11/12/2020 10:17:03 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
MONTERY PARK, CA 91754

FACILITY NAME:	HAWTHORNE TERRACE CARE HOME, LLC		FACILITY NUMBER:	198320095
ADMINISTRATOR:	HA, STEVEN		FACILITY TYPE:	740
ADDRESS:	4760 W 123RD ST		TELEPHONE:	(201) 562-8622
CITY:	HAWTHRONE	STATE: CA	ZIP CODE:	90250
CAPACITY:	14	CENSUS: 0	DATE:	10/30/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Steven Ha and Mary Hauf		TIME COMPLETED:	05:15 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	Licensing Program Analysts (LPA) Jey Cardenas made an announced visit, Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s pre-licensing was conducted telephonically via zoom with the Applicant Steven Ha, present was also Mary Hauf . An application was received by Community Care Licensing Department (CCLD) on 03/23/2020 for an initial application to serve elderly ages 60 years and over. The requested capacity is for six (6) non-ambulatory residents, eight (8) ambulatory residents, and zero (0) bedridden residents. Structure: Facility is a one-story family home with eight (8) bedrooms, two (2) full bathrooms, one (1) half bath and (1) third bathroom, living room, dining area, and kitchen. Garage is located in the back of the property. All exits are equipped with auditory devices with alert feature to monitor entrance/exits. Front yard landscape is in good condition at time of tele-visit. Washer/Dryer appliances are located adjacent from the kitchen. No firearms in the home. LPA observed working telephone located in dinning room. Mandated postings are located in the dining room. Bedroom Residents: Bedrooms #1, 2, 3,4 are approved for non-ambulatory residents and bedroom# 5,6,7,8 are designated for ambulatory. Bedrooms are equipped with one bed, nightstand, chair, and lightning. Bathrooms: full bathrooms have a working toilet, wash basin, bathtub, bathrooms have non-skid mats and grab bars. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, fitted sheet, blanket and bedspreads. Two (2) fully charged fire extinguishers available with service tags: Sep 2020, one is located in the dinning room, second is located in hallway near bedroom #5,6,7,8. Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in kitchen cabinet inaccessible and under lock. Smoke Detectors/Carbon Monoxide(s): Smoke alarms are hardwired and operational test by fire dept on Oct 2020. Facility is equipped with carbon monoxide located in hallway near bedroom #1,2,3,4. Appliances: Stove burners (gas), oven, microwave, coffee maker, two (2) refrigerators, one (1) large freezer, and washer/dryer are in working condition. Toxins: Cleaning supplies and

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey Cardenas	TELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020

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
MONTERY PARK, CA 91754

FACILITY NAME: HAWTHORNE TERRACE CARE HOME, LLC	FACILITY NUMBER: 198320095
	VISIT DATE: 10/30/2020

NARRATIVE

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toxins are stored and locked in kitchen sink cabinet Water Temperature: Hot water was tested in bathroom; temperature was 108 degrees Fahrenheit. Medication, First-Aid Kit & Book: Designated centrally stored medication area was locked and located in a cabinet space in hallway near bedroom #4. Facility has First Aid Kit and Manual, thermometer, scissors, sufficient bandages and one (1) tweezer. residents & Staff Files: Designated area for files is located in a locked file cabinet located in the dinning room. Applicant will not handle cash resources for residents. Pools/Jacuzzi & Pets: No bodies of water and no pets on these premises. Fire Clearance: Fire clearance was approved on 10/16/20

Component III was reviewed with applicant, no questions.

LPA reminded applicant the following items shall be posted always: Emergency numbers, Personal rights, Emergency Disaster Plan, Complaint Procedures, and facility sketch show emergency exits.

An exit interview was conducted, and a copy of this report has been furnished to the applicant. Accordingly, LPAs will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey Cardenas	TELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020

LIC809 (FAS) - (06/04)

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