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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320099
Report Date: 12/07/2022
Date Signed: 12/08/2022 04:58:26 PM

Document Has Been Signed on 12/08/2022 04:58 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:PATTERSON FAMILY HOMEFACILITY NUMBER:
198320099
ADMINISTRATOR:MASON, DAVIDFACILITY TYPE:
735
ADDRESS:2061 WEST 96TH STREETTELEPHONE:
(323) 777-4240
CITY:LOS ANGELESSTATE: CAZIP CODE:
90047
CAPACITY: 6CENSUS: 6DATE:
12/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:David MasonTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced required 1- year visit with the primary focus on Infection Control measures and using the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA was properly screened for COVID-19 symptoms and temperature was checked. LPA Bunker met Licensee David Mason and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved mitigation plan report. There are currently five (5), Westside Regional Center (WRC) Adult Residential Care Facility (ARF) consumers in placement. The facility's annual fees are current.

The following Domain will be observed and reviewed: Infection Control Practices "I will be using this tool and methods that have been developed to improve the efficiency and accuracy of the Department of Social Services facility inspections."

The facility is a single-family home located in a residential neighborhood. Licensee Mr. Mason and LPA Bunker toured the facility which consisted of the following: Living room, kitchen, breakfast nook, dining room, 4 bedrooms, 2 bathrooms, laundry area in the kitchen, locked medication cabinet in the dining room, shaded area, storage room, detached garage, and indoor/outdoor activity areas. The front and back yard landscape is in good condition at the time of the visit. During the tour, LPA observed the facility’s infection control practices.
See continued LIC809-C on page 2
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: PATTERSON FAMILY HOME
FACILITY NUMBER: 198320099
VISIT DATE: 12/07/2022
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Continued LIC809-C page 2

LPA observed a sanitizing station at the facility entrance; hand sanitizer, thermometer, and PPE supplies are readily available to staff. Sufficient paper, cleaning, and disinfecting supplies were observed. Mr. Mason indicates that the Licensee/Administrator reviews the PINS and is up to date on the PINs.

Documents are posted as mandated. Bedrooms contain the furniture mandated, Bathrooms are clean and operational. Personal accommodations were observed for safety, privacy, comfort, and non-skid surface mats. The kitchen was observed for its ability to prepare and serve food. The food service was reviewed for appropriate quantity and proper storage; there was an ample supply of perishable and nonperishable food. The resident’s medications were reviewed for proper storage, documentation, and system implementation. Medications are locked, and records are current. Common areas were observed for the ability to safely serve the needs of the clients, including cleanliness, and clearness of any potential hazards to the residents. The first aid kit is fully stocked with manual, smoke, and carbon monoxide detectors were in compliance, the hot water temperature was measured at 113.2 degrees Fahrenheit within the normal limits (105-120F degrees), the fire extinguisher is fully charged, adequate linen supply, the facility telephones are working The client's bedroom windows have no sliding window lock with thumbscrews, all exit doors were in compliance, the yard was free of debris hazards, and trash cans were covered. Staff was given training on dependent adult and elder abuse reporting. The facility conducted a fire drill on November 16, 2022.

There were no deficiencies cited.

Exit interview conducted.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022
LIC809 (FAS) - (06/04)
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