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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320145
Report Date: 02/08/2022
Date Signed: 03/01/2022 04:29:07 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 03/01/2022 04:29 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:ABSOLUTE MANAGED CARE IIIFACILITY NUMBER:
198320145
ADMINISTRATOR:MORGAN, LATRACIAFACILITY TYPE:
735
ADDRESS:4533 S. WILTON PLTELEPHONE:
(214) 240-4247
CITY:LOS ANGELESSTATE: CAZIP CODE:
90062
CAPACITY: 4CENSUS: 4DATE:
02/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Brandi Brooks, AdministratorTIME COMPLETED:
02:31 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ulysses Coronel conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA was met by LaTricia Morgan, administrator and Brandi Brooks Licensee and the purpose of today’s visit was explained. The facility is licensed to serve up to 4 ambulatory clients age range 18-59.

There are currently 4 South Central Regional Center clients in placement. All 4 clients are ambulatory. The facility is a single-story structure located in a residential neighborhood. It consists of the following: a living room, kitchen, dining room, 4 bedrooms, 2 bathroom, laundry room, indoor/ outdoor activity area, shaded area with chairs and a detached one car garage.

LPA and staff toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 117.6 F. A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is a enough perishable and non-perishable food available which is stored properly. Fire extinguisher was charged, smoke detectors and Carbon Monoxide detectors were operable.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations located in common areas and restrooms. LPA observed staff and residents were wearing face coverings, an isolation room and required postings throughout the facility.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2022
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 3
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: ABSOLUTE MANAGED CARE III
FACILITY NUMBER: 198320145
VISIT DATE: 02/08/2022
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LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

During todays visit LPA and the administrator observed a shopping bag full of clients C1's and former client C2's medications from previous months cycles ranging from January 2019 through December 2021 located in the storage room. Title 22 Division 6 Chapter 6 is being cited please see LIC809D.

Exit interview held and plans of corrections developed. A copy of the report and appeals rights were provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/01/2022 04:29 PM - It Cannot Be Edited


Created By: Ulysses Coronel On 03/01/2022 at 02:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ABSOLUTE MANAGED CARE III
FACILITY NUMBER: 198320145

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/22/2022
Section Cited
CCR
80075(l)(1)(A-D)

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Health Related Services. Prescription medications...which are not to be retained shall be destroyed by the facility administrator, or a designated substitute, and one other adult who is not a client. Both shall sign a record, to be retained for at least one year, which lists the following:...The date of destruction.
This requirement is not met as evidenced by:
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The administrator agreed to have the medications destroyed and submit a plan to ensure that medications which are not to be retained are destroyed. Proof of correction will be submitted by POC due date.
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Based on observation, interview record review, the licensee failed to ensure that medications which are not to be retained are destroyed. C1 and C2's medications from January 2019 trough December 2021 cycles were not destroyed, which poses/posed a potential health, safety or personal rights risk to persons in care.
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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:Janae Hammond
LICENSING EVALUATOR NAME:Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2022


LIC809 (FAS) - (06/04)
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