198320095-11-21-2022-11-AS-WGIS-CLDUXL-20221121145832

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320095
Report Date: 11/21/2022
Date Signed: 11/21/2022 02:58:41 PM

Document Has Been Signed on 11/21/2022 02:58 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:	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:	DATE:	11/21/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:22 AM
MET WITH:	Mary Hauf		TIME COMPLETED:	01:45 PM

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On November 21, 2022, Licensing Program Analyst (LPA) Wendy Gibbs, conducted an unannounced required annual visit with a primary focus on Infection Control measures using the CARE Inspection Tools. Upon arrival at the facility, LPA Gibbs met with House Administrator Josephine Hauf, and explained the purpose of today’s visit. The facility is licensed for fourteen (14) residents, approved for six (6) non-ambulatory and eight (8) ambulatory; hospice waiver for six (6). Currently there are eight (8) residents in the facility and three (3) staff.

Structure The facility is a single-story home in a residential area. The facility has seven (7) bedrooms, one (1) staff room, four (4) restrooms (2 full baths, 1shower, and 1 just facilities), kitchen, 2 sitting areas, laundry area, attached garage and an outside sitting area.

Physical Plant Outside grounds were toured, LPA observed multiple chairs and tables with umbrellas for residents use. There were no bodies of water. Walkways around the home were clear of obstructions or hazards.

Bedrooms LPA inspected all bedrooms. All bedrooms had necessary furniture which included: bed, dresser, nightstand, chair, ample lighting, and a closet. All beds had the required linens, mattress cover, fitted sheet, top sheet, blanket, comforter, and pillows. There were additional blankets and comforters in resident’s closets as well as personal need items (diapers, wipes, mats, gloves).

Bathroom All bathrooms were in good working order. There was ample supply of hand soap, and paper towels. Each shower was clean and free of mildew and had secured grab bars, nonskid matts, and/or a chair available. Water temperature measured between 112.4-118.2 degrees Fahrenheit.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2022

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: HAWTHORNE TERRACE CARE HOME, LLC	FACILITY NUMBER: 198320095
	VISIT DATE: 11/21/2022

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Linens & Hygiene LPA observed an ample supply of linens in the cupboard in the hallway. As well additional hygiene products.

Kitchen All appliances were in good working order. LPA observed a 3-day supply of perishable food and a minimum of 7 day supply of non-perishable food supply. The freezer in the kitchen and additional freezer in the garage are fully stocked. All dishes, cups, pans, and other cutlery in good condition. Knives were locked in a cabinet in the kitchen next to the sink and cleaning supplies are locked under the kitchen sink.

Common Areas Both sitting areas were clean and free of obstructions. There is enough seating for all residents. LPA observed books and games available for the residents. There was ample lighting in both rooms.

Laundry Washer and dryer were in good working condition. All soaps and softeners were locked in the cabinet’s above the washer and dryer.

Safety LPA viewed the emergency exit plan as well as emergency numbers posted. Smoke detectors and Carbon Monoxide detector are all in operating condition. The facility has two (2) Fire Extinguisher, which are fully charged, accessible, and inspected on 10/19/22. The First Aid kit was fully stocked and with the manual. The last emergency drill was on 11/12/22. LPA observed all necessary postings throughout the facility including, the local ombudsmen and “See something, Say Something,” as well as Covid Prevention Postings.

Files LPA reviewed four (4) Resident files and all files contained the required documentation. Also reviewed were three (3) staff files; all files contained the required documentation.

Medication LPA reviewed four (4) resident’s medications and matched them to the MARs. All medications were in their original packaging. Medications were centrally stored and locked in a cabinet inaccessible to residents.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2022

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: HAWTHORNE TERRACE CARE HOME, LLC	FACILITY NUMBER: 198320095
	VISIT DATE: 11/21/2022

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Infection Control 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 30-day supply of PPE were observed in the garage area. LPA observed all staff wearing a face covering.

LPA reviewed the Liability Insurance which is good through 08/2023.

No deficiencies were cited.

Exit interview was conducted with Josephine Hauf.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2022

LIC809 (FAS) - (06/04)

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