198320191-11-27-2023-11-AS-RCLD-CXZ24P-20231127160416

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320191
Report Date: 11/27/2023
Date Signed: 11/27/2023 04:04:43 PM

Document Has Been Signed on 11/27/2023 04:04 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	FORT FAITH RCFE		FACILITY NUMBER:	198320191
ADMINISTRATOR:	FORT, NISHA		FACILITY TYPE:	740
ADDRESS:	710 LACONIA PL		TELEPHONE:	(213) 362-8837
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90044
CAPACITY:	4	CENSUS: 2	DATE:	11/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:16 AM
MET WITH:	Marcia Bailey		TIME COMPLETED:	04:15 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	Licensing Program Analysts (LPA) Regina Cloyd made an unannounced visit, and met with staff, Marcia Bailey, to conduct an annual unannounced inspection using the CARE Tool. The facility is licensed to serve elderly ages 60 years and over. Approved capacity is for four (4) ambulatory residents, zero (0) non-ambulatory residents, and zero (0) bedridden residents. Structure: Facility is a one-story family home with three (3) bedrooms, (2) full bathrooms, living room/ dining area, and kitchen. A car port / shaded area is located on the front of the property; LPA observed two (2) bench to be used for resident seating. Total of two (2) exits; main exit located in living room, exit two is in bedroom #1. Front yard landscape is in good condition at time of visit. A locked closet/storage space located across from bedroom#3 is used for extra linens, towels, and hygiene supplies. Washer/Dryer appliances are located in the kitchen. There are no firearms in the home. Bedroom: Bedrooms are equipped with one bed per resident, night-stand, chair, and overhead lightning. Bathrooms: bathrooms have a working toilet, wash basin, tub/shower. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, fitted sheet, blanket and bedspreads. One fully charged fire extinguisher is located near the kitchen. Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in kitchen drawer inaccessible and under lock. Smoke Detectors/Carbon Monoxide(s): Facility is equipped with three (3) operational dual/ hardwired smoke detectors and carbon monoxide.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 11/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: FORT FAITH RCFE	FACILITY NUMBER: 198320191
	VISIT DATE: 11/27/2023

NARRATIVE

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Appliances: Stove burners (gas), oven, microwave, and washer/dryer are in working condition. There is one working (1) refrigerator in the home and working cordless telephone is located in the living room.

Toxins: Cleaning supplies and toxins are stored and locked in kitchen sink cabinet.

Water Temperature: Hot water was tested in bathroom #2; temperature was 118.2 Degrees F.

Medication, First-Aid Kit & Book: Designated centrally stored medication area was locked and located in a standing cabinet space located in the Living room. Sufficient bandages and one (1) tweezer. Facility has First Aid Kit, Manual thermometer and scissors.

Pools/Jacuzzi & Pets: No bodies of water and no pets on these premises.

5 staff records were reviewed, 5 out of 5 staff records had current first aid certificates. Two staff were interviewed.

2 resident records were reviewed and, 2 out of 2 residents records had Admission Agreements. Two residents were interviewed.

During record review, LPA did not observe 2 out of 4 health screening reports for staff, which poses a potential health and safety risk to the persons in care. During record review, LPA did not observe documentation of a medical assessment, signed by a physician, made within the last year for R#2.

Deficiencies are being cited based on LPA observation, interviews conducted and record review in accordance with the California Code of Regulations, Title 22, see LIC809D.

An exit interview was conducted, technical assistance provided, and plans of corrections were reviewed and developed with the Licensee. A copy of this report and appeal rights were discussed and left with Marcia Bailey.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 11/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/27/2023 04:04 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: FORT FAITH RCFE	FACILITY NUMBER: 198320191
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above for two out of four staff members. Staff files were missing the Health Screening Reports with TB results (LIC 503) which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/12/2023
	Plan of Correction
1 2 3 4	Licensee will email the Health Screening Reports with TB results (LIC 503) to regina.cloyd@dss.ca.gov by the due date. Licensee will also email an updated procedure adressing complaince with section 87411(f).

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: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 11/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

LIC809 (FAS) - (06/04)

Page: 4 of 15

Document Has Been Signed on 11/27/2023 04:04 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: FORT FAITH RCFE	FACILITY NUMBER: 198320191
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above for one out of two residents. Resident #2 lives at the facility and does not have a Physician's Report on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/12/2023
	Plan of Correction
1 2 3 4	Licensee will email the physician's report for R#2 to regina.cloyd@dss.ca.gov prior to the due date. Licensee will also email updated intake procedures addressing section 87458(a) compliance.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 11/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

LIC809 (FAS) - (06/04)

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