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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320160
Report Date: 03/08/2024
Date Signed: 03/08/2024 03:44:47 PM

Document Has Been Signed on 03/08/2024 03:44 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
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:
03/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:17 PM
MET WITH:Eboney Jones TIME COMPLETED:
03:48 PM
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On 03/08/23, Licensing Program Analyst (LPAs) Ernand Dabuet and Troy Watson conducted an unannounced annual required visit using the CARE Inspection Tool. LPA mets with house manager Eboney Jones. LPAs 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.

LPAs 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 117.1 -118.2 degrees F. A comfortable temperature of 73.0 degrees was maintained in the facility.

LPAs 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-#4 (S1-S4) 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: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: CARRIAGE CREST HOMECARE II
FACILITY NUMBER: 198320160
VISIT DATE: 03/08/2024
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During the visit, LPAs observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPAs observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

The facility is current on liability insurance coverage effective 03/23/24-03/23/25. The facility has a current surety bond coverage. The facility has a current administrator's certificate for Maria Roderick #60032379735.

No deficiencies during this inspection visit.

An exit interview conducted with Eboney Jones and a copy of the report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
LIC809 (FAS) - (06/04)
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