198320208-6-30-2021-11-AS-UCOL-C4GSHE-20210630135326

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320208
Report Date: 06/24/2021
Date Signed: 06/30/2021 01:53:35 PM

Document Has Been Signed on 06/30/2021 01:53 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	CATO Q CARE 135		FACILITY NUMBER:	198320208
ADMINISTRATOR:	CATO, SHAINNA		FACILITY TYPE:	735
ADDRESS:	628 E 135TH STREET		TELEPHONE:	(310) 604-1911
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90059
CAPACITY: 4		CENSUS: 4	DATE:	06/24/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:03 PM
MET WITH:	Pamela Cato		TIME COMPLETED:	04:34 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 06/24/2021 Licensing Program Analyst (LPA) Ulysses Coronel conducted an announced visit to the facility for purpose of a pre-licensing evaluation. Today’s pre-licensing evaluation was conducted telephonically with Shainna Cato, the administrator. LPA Coronel conducted a review of the Physical Plant, Bedrooms, Bathrooms, Supplies, Food Service, Medications, Records, Administration, Activities, Pe-Licensing Checklist and Component III Orientation. On 03/08/2021 an application was submitted to CCLD, for Initial license for an Adult Residential Facility to serve adults age range 18 through 59. The requested capacity is for 4 clients of which 2 may be non-ambulatory clients. The facility is single story family home located in a residential neighborhood, the facility consists of the following: Living room with a dining area, kitchen, 4 bedrooms, 2 bathrooms, laundry room, detached garage, shaded area, indoor/outdoor activity areas. Bedroom#1 is being used as an office/staff room, bedroom#2 is being used as an intake/centralized facility entrance, bedroom numbers 3 and 4 are both being used as shared bedrooms. MEDICATIONS There is a locked centralized storage area for client medications. PHYSICAL PLANT Facility is clean, sanitary, and in good repair. Protective devices are in place to include nonstop material on rugs. Indoor and outdoor passageways, stairways, inclines, ramps, open porches, and other areas of potential hazard are free of obstructions. There are no pools or bodies of water at this facility. All window screens are clean and in good repair. Facility temperature is between 68 degrees and 85 degrees. Stairways, inclines, ramps, open porches, and areas of potential hazard are well-lit and equipped with sturdy hand railings. Fire alarms and smoke alarms operate properly. Carbon monoxide detectors operate properly.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021

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

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CATO Q CARE 135	FACILITY NUMBER: 198320208
	VISIT DATE: 06/24/2021

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

BEDROOMS
Client bedrooms are large enough to allow for easy passage and to accommodate furniture, wheelchairs, walkers, or oxygen equipment. No client bedroom is a passageway to another room, bath or toilet. The barn door between bedroom #3 and #4 is not being used as an access to the backyard. The bathroom inside bedroom#3 is only being used by occupants of bedroom#3. There is a bed for each client with a mattress, mattress pad, bedsprings, and pillow(s) which are clean and in good repair. Mattresses and pillows are flame-retardant. There is dresser and closet space for each client that includes at least two (2) drawers or eight (8) cubic feet of dresser space per client. There is a chair and lamp for each client and at least one (1) night stand per two (2) clients.

BATHROOMS
There are 2 toilets and 2 washbasins available for clients, family, and personnel use. Bathroom(s) located near client bedrooms. The hot water temperature measured between 105 and 120 degrees F.

SUPPLIES
There are client personal hygiene supplies to include soap, toothpaste, toilet paper, and comb. There is a sufficient supply of clean linens to permit weekly changing or more of client top sheets, bottom sheets, bedspreads, blankets, pillowcases, mattress covers, bath towels, hand towels, and washcloths.

FOOD SERVICE
Dining room is near kitchen. Refrigerator(s) and freezer(s) are clean and large enough for the storage of at least two (2) days of perishable foods. Freezer is 0 degrees Fahrenheit. Refrigerator is a maximum of 45 degrees Fahrenheit. A seven (7) day supply of non-perishable food is present. There are sufficient amounts of tableware, tables, dishes, and utensils. There are sufficient amounts of equipment for the storage, preparation, and service of food. All equipment, dishes, and utensils are clean and well maintained. All kitchen, food storage, and preparation areas are clean.

RECORDS
There is confidential storage of personnel records at the facility. There is confidential storage of client records at the facility. All records are kept in bedroom#1/office.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CATO Q CARE 135	FACILITY NUMBER: 198320208
	VISIT DATE: 06/24/2021

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

ADMINISTRATION
The emergency exiting plan and emergency phone numbers are posted. Client Personal Rights are posted. Posting both sides of the Personal Rights form LIC 613 meets this requirement. Facility Visiting Policy is posted. Licensing Complaint Poster is posted.

ACTIVITIES
There is an outdoor activity space with a shaded area and furnished for outdoor use. There is at least one common room available to clients for visitors. There are activity supplies to include newspapers, magazines, and a variety of reading material.

MISCELLANEOUS
There are first-aid supplies to include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual. There is space and equipment for laundry. There is a space for clean linen storage and a separate space for soiled linen. There is an operating telephone available to clients.

PRE-LICENSING CHECKLIST
Completed by licensee and reviewed by LPA.
COMPONENT III
Information was provided about how to operate the facility within substantial compliance.

During the pre-licensing inspection certain items were observed which do not comply with applicable laws and regulations; the following items must be corrected, and proof of correction shall be submitted to the CCLD office to the attention of LPA by 06/28/2021. If additional time is required to complete noted items to correct, then the applicant will request an extension in writing prior to the due date. Some items may require a follow up inspection for verification of correction.
1. The applicant needs to submit a plan of correction for approval. That will address clients personal right issues, the bathroom area inside bedroom#3 does not have a door for privacy.

An exit interview was conducted, and a hard copy of this report has been furnished to Shainna Cato, the administrator. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to the applicant.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021

LIC809 (FAS) - (06/04)

Page: 3 of 3