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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320206
Report Date: 11/26/2022
Date Signed: 11/26/2022 04:20:20 PM

Document Has Been Signed on 11/26/2022 04:20 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:234TH HOMEFACILITY NUMBER:
198320206
ADMINISTRATOR:BOATNER, VERRETTAFACILITY TYPE:
735
ADDRESS:160 E. 234TH STREETTELEPHONE:
(310) 872-3326
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 4CENSUS: 1DATE:
11/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:58 PM
MET WITH:Verreta Boatner TIME COMPLETED:
04:17 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 11/26/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA met with the administrator Verreta Boatner. LPA explained the purpose of today’s visit. The facility is licensed to operate for four (4) ambulatory adults of which two (2) may be non-ambulatory ages 18 through 59. The clients are Harbor Regional Center consumers.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) clients' rooms, two (2) 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 or obstructions 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 adequately stocked at the time of the visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. A comfortable temperature of 76 degrees was maintained in the facility.

LPA observed the facility to be sanitary and appropriately furnished during 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 there is sufficient perishable and non-perishable food available and maintained adequately. A fire extinguishers were charged, and smoke detectors and carbon monoxide were operable. A review of Medication Records Administration (MAR) was maintained in order The facility has a working landline telephone. The staff had all current CPR/First Aid Training on file.

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 11/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/26/2022
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 4
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: 234TH HOME
FACILITY NUMBER: 198320206
VISIT DATE: 11/26/2022
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
INFECTION CONTROL:
During the visit, LPA observed the facility's infection control practices. LPA observed staff followed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). Posters mandated for inspection control were posted. The vaccinations of staff and residents were reviewed. The facility has a Mitigation Plan Report approved by CCLD on file along with Infection Control and Monkey Pox 2022 Plans.

DEFICIENCIES:
The water temperature for bathrooms tested at a range of 124.8 F and 132.9 F. LPA identified staff #1 (S1) did not have a current CPR/First Aid Training Certificate.

Deficiencies cited during this visit (see LIC 809-D).

An exit interview was conducted and a copy of this report and appeal rights were provided to Verreta Boatner.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/26/2022 04:20 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 11/26/2022 at 02:58 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: 234TH HOME
FACILITY NUMBER: 198320206

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation), the licensee did not comply with the section cited above. LPA tested water temperature for both bathrooms and it ranged from 124.8 and 132.9 This violation poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2022
Plan of Correction
1
2
3
4
The licensee will ensure that hot water temperature shall be maintained to regulate at 105.0 F and not more than 120.0F by Title 22 Regulation standards. Licensee will submit proof of correction by sent by fax with corrected temperature to 323-918-1781 by POC due date: 11/28/22.
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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 11/26/2022 04:20 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 11/26/2022 at 02:59 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: 234TH HOME
FACILITY NUMBER: 198320206

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
80075 Health Related Services (f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on (observation) and (review) the licensee did not comply with the section cited above. LPA identified staff #1 (S1) did not have a current CPR/First Aid certificate training on file. This violation poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2022
Plan of Correction
1
2
3
4
Licensee will adhere to Title 22 Regulations Section 80075 and ensure all staff working with clients will have a current CPR/First Aid trianing. Proof of correction must be faxed to LPA by POC due date: 12/12/22 at 323-981-1781.
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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2022


LIC809 (FAS) - (06/04)
Page: 4 of 4