198320095-11-29-2021-11-AS-JCAS-C92U9K-20211123142316

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320095
Report Date: 11/23/2021
Date Signed: 11/29/2021 05:29:31 PM

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:	HAUF, MARY		FACILITY TYPE:	740
ADDRESS:	4760 W 123RD ST		TELEPHONE:	(201) 562-8622
CITY:	HAWTHORNE	STATE: CA	ZIP CODE:	90250
CAPACITY:	14	CENSUS: 8	DATE:	11/23/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Mary Hauf		TIME COMPLETED:	02:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Jey Cardenas conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA Cardenas met with administrator Mary Hauf, and the purpose of todays visit was explained. LPA conducted a risk assessment, based on the assessment, the facility is clear of Covid-19 infection The facility is licensed for fourteen (14) residents, approved for six (6) non-ambulatory and eight (8) ambulatory; hospice waiver for six (6).

LPA met with the administrator and they both toured the inside and outside grounds of the facility. The one story residential house consists of eight (8) bedrooms; one (1) bedroom is used for live-in staff, two (2) full bathrooms, one (1) half bath and (1) third bathroom, living room, dining area, and kitchen, garage, backyard shaded area, washer/Dryer appliances are located adjacent from the kitchen.

During the tour, LPA observed the facility’s infection control practices. LPA verified that the facility has an approved mitigation plan report. LPA was properly screened for Covid-19 symptoms, temperature was checked and documented. LPA observed a sanitizing station at the facility entrance; visitors log with Covid-19 screening and temperature log, PPE supplies are readily available to staff, and an additional 90 day supply of PPE was observed in the garage area. Sufficient paper, cleaning, and disinfecting supplies were observed. The facility’s designated visitation area is the shaded backyard area. LPA observed all staff wear a face covering. LPA didn’t observe required postings (visitors policy, signs posted to promote hygiene and distancing, cough etiquette, hand washing in all sinks, report acute respiratory illness) throughout the facility. CCLD PINS were readily available to staff and residents.

All rooms were inspected, beds in shared bedrooms are at least six feet or three feet head to toe. beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed.

Resident bathrooms were checked, sufficient liquid soap and paper towels were observed. Toilets and

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey Cardenas	TELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021

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
MONTERY PARK, CA 91754

FACILITY NAME: HAWTHORNE TERRACE CARE HOME, LLC	FACILITY NUMBER: 198320095
	VISIT DATE: 11/23/2021

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water faucets worked properly, grab bars were secure, LPA observed bathtub to have scum and dirt particles, LPA was informed that bathroom tub is not used due to residents ambulatory status, LPA indicated bathtub shall remain clear regardless of use. On 11/23/21 LPA tested water and temperature measured at 121.6 degrees F in bathroom. Comfortable temperature was maintained in the facility.

LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in a locked storage separate cabinets. Centrally stored medications were observed stored in their originally received containers and kept safe and locked and inaccessible to residents in care. One Carbon Monoxide was tested, and in operating condition. The facility has two (2) Fire Extinguisher, which was checked and found to be fully charged, accessible, and inspected on 11/4/2021. The First Aid kit was available and fully stocked. There are no security bars or weapons on the premises.

Outside grounds were toured, and no bodies of water were observed. Walkways around the home were clear of hazards. Common areas were clean and clear of hazards; doorways were free of obstructions. No bodies of water present.

Advisory Notes with technical assistance were issued:

1. Ensure staff are fit tested for respirators and tests/training's are documented in staff files.

2. Ensure required posters are posted throughout the facility

3. Windowsill in residents bedrooms were observed with dust and dirt particles.

4. Room #7 is missing a screen, room is currently vacant

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey Cardenas	TELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/23/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/24/2021 Section Cited	1 2 3 4 5 6 7	Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature... this requirement not met as evidenced by:
	8 9 10 11 12 13 14	O 11/23/2021 LPA Cardenas measrued hot water in bathroom and teperature measured at 121.6 degrees F. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey Cardenas	TELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021

LIC809 (FAS) - (06/04)

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