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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320108
Report Date: 08/04/2021
Date Signed: 08/04/2021 12:16:09 PM

Document Has Been Signed on 08/04/2021 12:16 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:ATARAXIS HOMES #1FACILITY NUMBER:
198320108
ADMINISTRATOR:BUCKMAN, JAMESFACILITY TYPE:
740
ADDRESS:6732 WOOSTER AVETELEPHONE:
(323) 573-4554
CITY:LOS ANGELESSTATE: CAZIP CODE:
90056
CAPACITY: 6CENSUS: 6DATE:
08/04/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:James Buckman, Licensee TIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Jennifer Jones conducted an unannounced required annual visit to Ataraxis Homes #1. The home is license for a Residential Care Facility for the Elderly to serve Elderly residents age 60 years and older. The facility is licensed for (6) Non-Ambulatory residents of which 1 residents maybe bedridden. The home has an approved hospice waiver of 3 and dementia care plan approved.

The single story home with an attached garage is currently located in a residential area. The home currently has 7 resident bedrooms, 3 resident bathrooms and 1 staff/guest bathroom. The resident bedrooms are spacious with overhead lighting and will easily accommodate the resident's furnishings. The home has two yard areas with table, chairs and umbrella. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured between 105-120 degrees in the resident restroom. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked in the hallway. The kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. LPA Jones observed two refrigerators in the kitchen and an additional freezer located in the garage with frozen food.
SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jennifer Jones
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2021
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
MONTEREY PARK, CA 91754
FACILITY NAME: ATARAXIS HOMES #1
FACILITY NUMBER: 198320108
VISIT DATE: 08/04/2021
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All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly and fire extinguisher was fully charged. Carbon monoxide detector was operational. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

During the visit, LPA observed the facility infection control practices. LPA observed a screening station with sanitizer at the entry of the facility and additional sanitation/PPE supplies located in the office inaccessible to the residents. LPA observed a sign in sheet and temperature log for visitors. LPA's temperature was checked by facility staff at the entry. LPA observed staff wearing mask. Each residential has their own individual room for isolation and required postings are throughout the facility. The licensee advised LPA that visitors have the option to meet with the residents inside or outside by appointment only.

No deficiencies cited:

Exit interview conducted and a copy of report was given to the licensee.

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jennifer Jones
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021
LIC809 (FAS) - (06/04)
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