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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320157
Report Date: 03/29/2023
Date Signed: 04/07/2023 11:55:12 AM

Document Has Been Signed on 04/07/2023 11:55 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: DATE:
03/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Zoei Clarke, AdministratorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Ana Soto conducted an unannounced Annual inspection visit to the above facility. LPA was met by Angelina Montes, Care giver and later met with Zoei Clarke, Administrator and the purpose of today’s visit was explained.

There are currently (4) South Central LA Regional Center consumers in placement. All (4) clients are ambulatory. (0) non-ambulatory. The facility is a single-story structure with front and side ramps located in a residential neighborhood. It consists of the following: 3 bedrooms, 2 bathrooms, family room/Kitchen, office, living room, dining room, laundry room in the detached 2 car garage.

LPA and Care giver toured the entire facility inside and out. Documents are posted as mandated by the DPH and CCLD. Bedrooms 1 - 4 are occupied by clients and contain the mandated furniture. Bedroom #1 has the bottom 3 broken wood slats of the window shudder and wall scrapped and paint pealing on the south wall of bedroom. There are no staff bedrooms. The (1) bathrooms is clean and operational. Bathroom #2 has a hole in the wall above the sink. Side wall next to bathroom #2 door is scrapped and paint pealing. The bottom kitchen cabinet next to the stove has a handle missing. Staffing & Personnel Records - 4 staff file are current. Clients Rights Information & Client Rec - Incident Reports - 4 client file are current along with medications and P&I. linens and personal hygiene supplies are adequate. Food Service - Ample supply of perishable and nonperishable food. manual. Operational Requirement - shaded area, indoor and outdoor activity area, Physical Plant Environmental - (1) fire extinguishers is fully charged. First Aid kit complete and with The water temperature is at 118.7 degrees. Fahrenheit. A comfortable temperature is maintained in the facility. Smoke detectors and carbon monoxide detector are in compliance and operational. hazardous toxins and/or items are inaccessible to clients. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to clients. Exit, walkways and/or passageways, front yard and back yard are free of debris and/or hazards.



SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 03/29/2023
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The facility is in good repair. Infection Control practices. LPA observed a sanitizing station at the facility entry & visitors and temperatures are logged and checked, sanitizer/soap, paper towels, in all the bathrooms and additional sanitation supplies are stored in the family room/ kitchen. LPA observed staff wearing masks, client private rooms will be converted to isolation rooms (if needed) No -trash cans with lids, No-cart for PPE’s, No -mitigation plan posted and/or in folder, No-Fit testing completed for staff, No - infectious Control Plan posted and/or in folder, No- Emergency infectious Plan posted and/or in folder, and required postings throughout the facility. Visitor designated area, facility has internet & IPAD for clients to use, client’s temperatures are checked and logged (once a day). Emergency contacts updated and posted; PPE's are enough for 30 days. All clients and staff are vaccinated and boosted.

Due to time constraints, LPA could complete the annual inspection and all domains. LPA will return at a later date to complete the rest of annual inspection and domains.

Technical Advisories (TA) issued.


1. No -trash cans with lids

2. No-cart for PPE’s

3. No -mitigation plan posted and/or in folder

4. No-Fit testing completed for staff

5. No - infectious Control Plan posted and/or in folder

6. No- Emergency infectious Plan posted and/or in folder,

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023
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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: 03/29/2023
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According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiencies and issued citations.

Due to technical difficulties (printer not operational) LPA will email reports.



An exit interview was conducted with Zoei Clarke, Administrator and a hard copy of report was provided and Appeal Rights via email.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023
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Document Has Been Signed on 04/07/2023 11:55 AM - It Cannot Be Edited


Created By: Ana Soto On 03/29/2023 at 03:38 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: NASHARI RESIDENTIAL CARE
FACILITY NUMBER: 198320157

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2023

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) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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Type B
Section Cited
CCR
80076(a)(19)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (19) All equipment, fixed or mobile, dishes, and utensils shall be kept clean and maintained in safe condition.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
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:Ana Soto
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2023


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