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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320206
Report Date: 10/19/2024
Date Signed: 10/19/2024 05:04:30 PM

Document Has Been Signed on 10/19/2024 05:04 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:234TH HOMEFACILITY NUMBER:
198320206
ADMINISTRATOR/
DIRECTOR:		BOATNER, VERRETTAFACILITY TYPE:
735
ADDRESS:160 E. 234TH STREETTELEPHONE:
(310) 872-3326
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 4CENSUS: 4DATE:
10/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:10 PM
MET WITH: Ebeagbor Emuobonuvie.TIME VISIT/
INSPECTION COMPLETED:
03:31 PM
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On 10/19/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with the Program Supervisor Ebeagbor Emuobonuvie . LPA explained the purpose of today’s visit. The facility is licensed to operate for four (4) ambulatory adults ages 18 through 59 of (2) may be non-ambulatory. 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 water temperature of 108.9 degrees F. A comfortable temperature of 70 degrees F. 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 extinguisher was charged, and smoke detectors and carbon monoxide were operable. A review of Medication Records Administration (MAR) and Fire Drills were observed to be maintained in order and accurately. The facility conducted Fire/Safety Drill on 08/22/24. The facility has a working landline.

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2024
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: 234TH HOME
FACILITY NUMBER: 198320206
VISIT DATE: 10/19/2024
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted. A review of staff and client files were found to be maintained in order.

An audit of client #1-#4 (C1-C4) files and staff #1-#4 (S1-S4) personnel files. The facility is current on CCL license annual fees.

Deficiencies:
  • During client's audit of personnel records, staff #2 did not have a current First Aid/CPR certificate on file.
  • Program Supervisor's personnel records was not available for licensing to inspect, audit, and copy upon demand during normal business hours.


According to the California Code of Regulations (Title 22, Division 6, Chapter 6), the following deficiencies has been observed and citation issued (ref. LIC 9099-D).

An exit interview was conducted, and a copy of this report was provided to program supervisor Ebeagbor Emuobonuvie.

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 Proof of Corrections (POC) is cleared. *

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/19/2024 05:04 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 10/19/2024 at 02:34 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: 234TH HOME
FACILITY NUMBER: 198320206

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(c)
80066 Personnel Records (c) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. LPA identified program supervisor did not personnel records available for licensing to inspect and audit upon demand during normal business hours. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/09/2024
Plan of Correction
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Licensee will ensure to all personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Proof of correction of program supervisor file must be available for audit by POC due date 11/09/24. POC must be sent to LPA Dabuet at: ernand.dabuet@dss.ca.gov
Type B
Section Cited
CCR
80075(f)
Health Related Services. Staff providing care and supervision shall receive first aid training from qualified agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review, the licensee did not comply with the section cited above. LPA identified staff #2 did have a current First Aid/CPR on file during inspection visit. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/09/2024
Plan of Correction
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Licensee will ensure that all personnel staff must completed training with a valid First Aid/CPR. Staff providing care and supervision must have completed First Aid/CPR on file. Proof of correction must be sent to LPA Dabuet at: ernand.dabuet@dss.ca.gov
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: 10/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2024


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