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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320157
Report Date: 03/22/2022
Date Signed: 03/22/2022 10:43:05 AM

Document Has Been Signed on 03/22/2022 10:43 AM - 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:NASHARI RESIDENTIAL CAREFACILITY NUMBER:
198320157
ADMINISTRATOR:CLARKE, ZOIEFACILITY TYPE:
735
ADDRESS:10779 CAPISTRANO AVENUETELEPHONE:
(310) 627-9208
CITY:LYNWOODSTATE: CAZIP CODE:
90262
CAPACITY: 4CENSUS: 3DATE:
03/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:44 AM
MET WITH:Zoie ClarkeTIME COMPLETED:
11:15 AM
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 Zoie Clarke, administrator and the purpose of today’s visit was explained. The facility is licensed to serve 4 clients age 18 thru 59 years; of which up to to 2 clients may be non-ambulatory.

There are currently 3 South Central Los Angeles Regional Center clients in placement. The facility is a single-story structure located in a residential neighborhood. The home consists of 3 Client Bedrooms, 2 Bathrooms, Living Room, Kitchen, and Dining area.

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 119.8 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 nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. Fire extinguisher was charged, smoke detectors and Carbon Monoxide 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, an isolation room and required postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2022
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 10
Document Has Been Signed on 03/22/2022 10:43 AM - It Cannot Be Edited


Created By: Ulysses Coronel On 03/22/2022 at 10:05 AM
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: NASHARI RESIDENTIAL CARE
FACILITY NUMBER: 198320157

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above the patio chair and the window shutter in bedroom 1 are in disrepair which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2022
Plan of Correction
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The administrator agreed to have the above items repaired and will create a plan to ensure that the facility is kept safe and in good repair at all times for the safety and well-being of clients, employees and visitors. Proof of corrections will be submitted to LPA via email at ulysses.coronel@dss.ca.gov.
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in the side gate is pad locked which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2022
Plan of Correction
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The administrator agreed to have the gate unlocked and will create a plan to ensure that all outdoor passageways and other areas of potential hazard shall be kept free of obstruction.. Proof of corrections will be submitted to LPA via email at ulysses.coronel@dss.ca.gov.
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: 03/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2022


LIC809 (FAS) - (06/04)
Page: 2 of 10
Document Has Been Signed on 03/22/2022 10:43 AM - It Cannot Be Edited


Created By: Ulysses Coronel On 03/22/2022 at 10:05 AM
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: NASHARI RESIDENTIAL CARE
FACILITY NUMBER: 198320157

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above the vanity mirrors in bathrooms 1 and 2 were not installed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2022
Plan of Correction
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The administrator agreed to have the vanity mirrors re-installed and create a plan to ensure that each clients are provided furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. Proof of corrections will be submitted to LPA via email at ulysses.coronel@dss.ca.gov.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 03/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2022


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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: NASHARI RESIDENTIAL CARE
FACILITY NUMBER: 198320157
VISIT DATE: 03/22/2022
NARRATIVE
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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 today’s visit the LPA Coronel observed the following deficiencies: 1. The patio chair and the window shutter in bedroom 1 was in disrepair. 2. The vanity mirrors in bathrooms 1 & 2 were not installed. And 3. The side gate is pad locked. Title 22, Division 6 and Chapter 6 is being cited on attached LIC809D form.

Plans of corrections were developed and exit interview held. A copy of the report and appeals rights were provided to was provided to Zoie Clarke, Administrator.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022
LIC809 (FAS) - (06/04)
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