<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320160
Report Date: 03/24/2023
Date Signed: 03/24/2023 11:54:55 PM

Document Has Been Signed on 03/24/2023 11:54 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:CARRIAGE CREST HOMECARE IIFACILITY NUMBER:
198320160
ADMINISTRATOR:RODERICK, TOMFACILITY TYPE:
735
ADDRESS:23124 CAROLDALE AVENUETELEPHONE:
(424) 477-5112
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 4CENSUS: 4DATE:
03/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:54 AM
MET WITH:Eboney Jones TIME COMPLETED:
04:31 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 03/24/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with house manager Eboney Jones. LPA explained the purpose of today’s visit. The facility is licensed to operate for (2) ambulatory and (2) non-ambulatory adults ages 18 through 59. The facility is approved for (1) hospice client. The consumers are Harbor Regional Center clients.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) clients' rooms, two (2) common bathrooms, a living area, a dining area, a kitchen, and an outside patio area.

LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were stocked during the visit. Bathrooms were operational. The water temperature measured 110.7 degrees F. A comfortable temperature of 72.0 degrees was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. The fire extinguisher was charged, and smoke detectors and carbon monoxide were operable. A review of the Medication Records Administration (MAR) was observed to be maintained in order and accurately. A working landline telephone was available and operable. An inspection audit of client #1-#4 (C1-C4) service records and staff #1-#6 (S1-S6) personnel files were complete and in order.

Evaluation Report continues LIC 9099-C
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2023
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 3
Document Has Been Signed on 03/24/2023 11:54 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 03/24/2023 at 03:50 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: CARRIAGE CREST HOMECARE II
FACILITY NUMBER: 198320160

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited. Staff #3 (S3) was identified without a Health Screening on file. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/07/2023
Plan of Correction
1
2
3
4
The licensee/administrator shall adhere to Title 22 Section 80066 and ensure that all staff has a Health Screening on file. Proof of correction must be sent to LPA on or before 04/07/23.
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. LPA identified staff #3 (S3) did not have (TB) test completed and on file. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/07/2023
Plan of Correction
1
2
3
4
The licensee/administrator shall adhere to Title 22 Section 80066 and ensure that all staff has a (TB) test on file. Proof of correction must be sent to LPA on or before 04/07/23.
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:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
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: CARRIAGE CREST HOMECARE II
FACILITY NUMBER: 198320160
VISIT DATE: 03/24/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
DEFICIENCIES:

LPA identified staff #3 (S3) did not have a Health Screening LIC 503 or Tuberculosis Bacteria (TB) test on file.
According to the California Code of Regulations (Title 22, Division 6, Chapter 1), the following deficiency has been observed and a citation issued (ref. LIC 9099D).
An exit interview was conducted with Eboney Jones and a copy of the report and appeal rights were provided.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until POCs are cleared.*
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3