198320240-3-18-2023-11-AS-JCAN-CQ2R99-20230318124911

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320240
Report Date: 03/18/2023
Date Signed: 03/18/2023 02:13:55 PM

Document Has Been Signed on 03/18/2023 02:13 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:	AMAZING EFFORTS VII, LLC		FACILITY NUMBER:	198320240
ADMINISTRATOR:	HENSON, TAMARA		FACILITY TYPE:	735
ADDRESS:	6513 4TH AVE		TELEPHONE:	(323) 236-8523
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90043
CAPACITY:	4	CENSUS: 2	DATE:	03/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	ADMINISTRATOR TAMARA HENSON		TIME COMPLETED:	01:00 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 03/18/2023 at 08:45 AM, Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced annual inspection visit at the Amazing Efforts VII LLC Facility. LPA Calderon was allowed entry into the facility by Administrator Tamara Henson. Administrator Tamara Henson was asked questions regarding the full care tools control package sections. Administrator Tamara Henson took LPA Calderon temperature prior to entrance into the facility. The facility is licensed for four (4) adult clients with developmental disabilities. Currently, there are two (2) residents residing in the facility with developmental disabilities. LPA Calderon explained to Administrator Tamara Henson, the purpose of the one-year (1) Annual Inspection visit, and escorted LPA Calderon on a tour of the entire inside and outside of the facility grounds. As part of the inspection, LPA Calderon reviewed: two (2) resident service records, two (2) resident medication records, two (2) staff records. LPA Calderon interviewed two (2) resident and two (2) staff members for visit. LPA Calderon inspected the facility to include all common areas, bedrooms, and bathrooms. The facilities’ last fire drill was conducted on 03/03/2023. The one-story residential home consists of three (3) resident bedrooms, two (2) resident bathrooms, living room, dining room, family room, kitchen, office area, attached garage with washer and dryer / storage area, backyard with table and chairs. No weapons are stored in the premises. Kitchen was inspected and observed to be clean and non-operational. Currently licensee is putting new floors in living room and kitchen area. New stove and other appliances will be going in. licensee states that all work will be done by 03/20/2023 and licensee has hired outside vendors for food services. A two-day (2) supply perishable and seven-day (7) supply of non-perishable foods are present in the facility. Emergency Water seven-day (7) supply is found in the garage.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2023

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: AMAZING EFFORTS VII, LLC	FACILITY NUMBER: 198320240
	VISIT DATE: 03/18/2023

NARRATIVE

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LPA Calderon observed that all facility rooms are clean and in good repair. A comfortable temperature was observed, and the facility has mini splits for air and heating. LPA Calderon observed the following during inspection of resident’s rooms: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, LPA Calderon observed fully stocked closet with bedding, towels, and toiletries supplies. Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. LPA Calderon observed bathrooms were found to be within Title 22 regulation. Bathroom #1 hot water temperature properly measured at 106 degrees Fahrenheit, and bathroom #2 hot water temperature properly measured at 107 degrees Fahrenheit. Kitchen hot water temperature properly measured at 108 degrees Fahrenheit. Facility (1) carbon Monoxide and (5) Smoke Detectors battery operated and were tested and are working properly. The facility one (1) Fire Extinguishers were checked and found to be fully charged and accessible. All exit doors in the facility have alarm systems. All toxins and knifes are locked/secured and inaccessible to residents. Medications are centrally stored and in a locked storage cabinet in the office. Facility first aid kit one (1) is fully stocked with manual was checked and in order. Outside grounds were toured and no bodies of water were observed. All Exits/ Walkways around the home were free of debris and hazards. Outside patio accessible to residents. LPA Calderon reviewed two (2) resident files and found to be complete. LPA Calderon reviewed two (2) resident medications and they were all found to be administered according to doctor's orders. LPA Calderon reviewed five (5) staff files were checked and have the required documents. LPA Calderon noted the Administrator Tamara Henson Certification # 6002954735 expiration date of 04/13/2023 was valid at time of visit. The facility does handle resident's money/cash resources and Surety bond is needed. Nationwide Mutual Insurance Company Bond Department #7901003361, bond value $1000.00 was valid at time of inspection. Commercial General Liability Policy #PAC2382496 policy period from 10/06/2022 to 10/06/2023 and a Commercial Professional Liability Insurance Policy #PAC2382496 policy period from 10/06/2022 to 10/06/2023 underwritten by Great American Assurance Company, coverage 1,000,000/3,000,000 is valid at time of inspection. LPA Calderon spoke to Administrator Tamara Henson who will email full copy of insurance contact which shows all coverages to LPA Calderon on 03/28/2023. All the required documents are posted in the facility in a clearly visible area to all staff, clients, and guests. LPA Calderon reviewed LIC500 and noted all staff associated to facility per LIS. LPA Calderon reviewed the resident roster, LPA Calderon confirmed residents’ interview are currently on facility resident roster.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2023

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: AMAZING EFFORTS VII, LLC	FACILITY NUMBER: 198320240
	VISIT DATE: 03/18/2023

NARRATIVE

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

LPA Calderon advised the Administrator Tamara Henson to continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA Calderon did not observe any deficiencies therefore NO citations were issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Administrator Tamara Henson.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2023

LIC809 (FAS) - (06/04)

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