198320239-2-24-2023-11-AS-DESA-CPCVAC-20230224151543

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320239
Report Date: 02/22/2023
Date Signed: 02/24/2023 03:15:48 PM

Document Has Been Signed on 02/24/2023 03:15 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:	HISGRACE COTTAGE		FACILITY NUMBER:	198320239
ADMINISTRATOR:	LEWIS, KRISTA		FACILITY TYPE:	735
ADDRESS:	1656 W 131ST STREET		TELEPHONE:	(310) 573-5840
CITY:	COMPTON	STATE: CA	ZIP CODE:	90222
CAPACITY: 6		CENSUS: 0	DATE:	02/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:01 AM
MET WITH:	LEWIS, KRISTA		TIME COMPLETED:	12:33 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

An unannounced Annual and infection control visit was done by David España, a Licensing Program Analyst (LPA). LPA España was met by Mrs Krista Lewis, Administrator, and the intent of the visit was explained. Today's visit was at a licensed facility to assist six people with developmentally disabled clients (i.e., Age range 18 through 59. approved for (6) ambulatory).

Currently, Mrs. Lewis stated the facility has reapplied to become a four (4) client facility (i.e., capacity). LPA España observed there were no clients as of 02/22/2023. LPA España was provided information about where they plan to receive clients, namely, the South Central Regional Center. LPA España observed a single-story building in a residential neighborhood. It features two bathrooms (one bathroom between bedrooms 1 and 2), a family room/dining area, a kitchen, a living room, covered space, indoor and outdoor storage facilities, and an attached garage.

LPA España and Mrs. Lewis conducted a physical facilities inspection. In client rooms, no bodies of water or firearms/ammunition exist. The mattresses and bedding were in acceptable condition, and adequate lighting and personal belongings items were not observed due to no client at this time. Both the walls and floors were in pristine shape. Sheets and a heater are located in the facility; however, there is no air conditioning. It was established that the restrooms complied with Title 22 regulations and were operational. The temperature of the water was 120.9 degrees Fahrenheit in the resident restroom, and in staff restrooms, it read 122.9 degrees Fahrenheit which is adjacent to Kitchen. Upon inspection, a comfortable temperature was observed at the facility to be clean and well-equipped. Clients can access storage and personal hygiene items.

LPA España observed that cleaning supplies, poisons, or sharp objects were not accessible to clients. The kitchen was well-stocked with both perishable and nonperishable food. 4 Carbon monoxide detectors and 2 fire extinguishers (one in the hallway and one in the kitchen area) were working.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023

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 2

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: HISGRACE COTTAGE	FACILITY NUMBER: 198320239
	VISIT DATE: 02/22/2023

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

During the visit, LPA España observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations (located in common areas and restrooms). LPA España observed staff wearing face coverings, an isolation room and required postings throughout the facility. LPA España observed the facility has a 30-day supply of Personal Protective Equipment (PPEs).

During today's examination, there were no deficiencies observed.

Exit interview administered. The report was made accessible to Mrs. Krista Lewis, Administrator.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2