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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320144
Report Date: 02/15/2023
Date Signed: 02/28/2023 07:20:20 PM

Document Has Been Signed on 02/28/2023 07:20 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:SMITH FAMILY RESIDENTIAL CAREFACILITY NUMBER:
198320144
ADMINISTRATOR:BEVERLY, KIMBERLYFACILITY TYPE:
735
ADDRESS:10518 S. 7TH AVENUETELEPHONE:
(323) 777-6161
CITY:INGLEWOODSTATE: CAZIP CODE:
90303
CAPACITY: 6CENSUS: 4DATE:
02/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
07:30 AM
MET WITH:Kenya BrownTIME COMPLETED:
11:15 AM
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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 with Licensee Kenya Brown and explained the purpose of today's Annual Inspection. LPA Bunker verified that the facility has an approved mitigation plan report. LPA Bunker verified all current staff fingerprints cleared/associated with the facility. There are currently four (4), Westside Regional Center 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-story family home located in a residential neighborhood. Licensee Ms. Brown, LPAs Bunker, and Alvizar toured the facility which consisted of the following: Living room, 5 bedrooms, and 3 1/2 bathrooms. There is a check-in station, living room, full kitchen/dining area, family room, kitchenette/dining area, sitting area, laundry room, locked supply closet, laundry room, patio area, shaded area, and indoor/outdoor activity areas. The front and back yard landscape is in good condition at the time of the visit.
Bedrooms #1-5 are designated as clients' bedrooms. The bedrooms have a twin bed, dresser, chest of drawers, 2 chairs, nightstand, lamp, and 2 tables, There is a bedroom designated for living in staff.

During the tour, LPA observed the facility’s infection control practices. 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. Ms. Brown indicates that the administrator reviews the PINS and is up to date on the PINs. See continued LIC809-C on page 2
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2023
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: SMITH FAMILY RESIDENTIAL CARE
FACILITY NUMBER: 198320144
VISIT DATE: 02/15/2023
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Continued LIC809-C page 2

Documents are posted as mandated at the entrance and on walls throughout the home. The following Title 22 regulated areas were audited and found to be in compliance: Bedrooms contain the required furniture. The client’s bedrooms were inspected for safety, privacy, and comfort. The living areas are clean, bathrooms are clean and operational. The first aid kit is fully stocked with a manual, hot water temperature at 108.5 degrees Fahrenheit, working telephone, smoke and carbon monoxide detectors were in compliance, fire extinguishers are fully charged, medications were centrally stored and properly locked in the laundry room cabinet and records are current, ample supply of perishable and nonperishable food, adequate linen supply, fire/emergency drill conducted on February 01, 2023. No firearms on the premises, the client's bedroom windows have no sliding window locks with thumbscrews, all exit doors were in compliance, covered trash cans, and no bodies of water were present. Hazardous items are inaccessible to clients, the yard is free of debris and hazards.

Staff was given training on dependent adult and elder abuse reporting.

There were no deficiencies cited.

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

DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023
LIC809 (FAS) - (06/04)
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