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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320282
Report Date: 06/15/2024
Date Signed: 06/15/2024 03:57:49 PM

Document Has Been Signed on 06/15/2024 03:57 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:ACOSTA FAMILY HOME IIFACILITY NUMBER:
198320282
ADMINISTRATOR/
DIRECTOR:		ACOSTA, ASHLEYFACILITY TYPE:
735
ADDRESS:1811 EAST ABILA STREETTELEPHONE:
(310) 604-8740
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 4CENSUS: 4DATE:
06/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:02 AM
MET WITH:Anet Alegria & Ashley Acosta TIME VISIT/
INSPECTION COMPLETED:
03:31 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 06/15/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with House Manager Anet Alegria. LPA explained the purpose of today’s visit. The facility is licensed to operate for (3) ambulatory and (1) non-ambulatory adults ages 18 through 59. The residents are all Harbor Regional Center consumers.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: (4) client's rooms, (2) bathrooms (1) staff bathroom, a living area, a dining area, a kitchen, an office, an outside seating area, and a garage.

LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 105.4 degrees F. A comfortable temperature of 73 degrees F. was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. A fire extinguisher was charged. A review of the Medication Records Administration (MAR) was observed to be maintained in place.

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. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.
(Evaluation Report continues LIC 809-C)
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2024
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 5
Document Has Been Signed on 06/15/2024 03:57 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 06/15/2024 at 01:32 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: ACOSTA FAMILY HOME II
FACILITY NUMBER: 198320282

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(4)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (4) Request and be approved for a transfer of a criminal record exemption, as specified in Section 80019.1(r), unless, upon request for the transfer, the Department permits the individual to be employed, reside or be present at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. LPA identified two staff #4 & staff #5 were not associated at this facility and is included on LIS 500. According to administrator both staff are working at this facility without proper association and no LIC 9162 Criminal Clearance Background Transfer. This violation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2024
Plan of Correction
1
2
3
4
Licensee/amdinistrator will submit an LIC 9162 or manually associated staff #4 & #5 in CCL Guardian by proof of correction date: POC 06/16/24.
Section Cited
Personnel Records
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: 06/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 06/15/2024 03:57 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 06/15/2024 at 01:32 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: ACOSTA FAMILY HOME II
FACILITY NUMBER: 198320282

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 identified baseboard molding in bathroom #3 peeling from the wall and need to be repaired or replaced. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2024
Plan of Correction
1
2
3
4
LIcensee/administrator will ensure to have the base molding in bathroom #3 repaired or replaced by plan of correction date: POC 07/15/24 to ernand.dabuet@dss.ca.gov
Type B
Section Cited
CCR
85064(f)
Administrator Qualifications and Duties
(f) When the administrator is absent from the facility there shall be coverage by a designated substitute, who meets the qualifications of Section 80065, who shall be capable, of, and responsible and accountable for, management and administration of the facility in compliance with applicable law and regulation.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. LPA identified there is no designated back up qualified administrator on file. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2024
Plan of Correction
1
2
3
4
LIcensee/administrator will ensure to designate a qualified administrator for for this facility. Plan of correction must be submitted by due date: POC - 07/05/24 to 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: 06/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 06/15/2024 03:57 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 06/15/2024 at 01:33 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: ACOSTA FAMILY HOME II
FACILITY NUMBER: 198320282

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. LPA identified staff #4 did not have a health screening LIC 503 on file and no proof of TB test results. This violation which poses/posed a potential health, safety orlt. personal rights risk to persons in care.
POC Due Date: 06/29/2024
Plan of Correction
1
2
3
4
LIcensee/administrator must comply to Title 22 80066 and submit a Health Screening LIC 503 with TB Results for staff #4 by POC due date: 07/29/24 at ernand.dabuet@dss.ca.gov
Type B
Section Cited
CCR
80069(b)(1)
Personnel Records
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment. (1) Such assessment shall be performed by a licensed physician, or designee, who is also a licensed professional, and the assessment shall not be more than one year old when obtained.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, and record review, the licensee did not comply with the section cited above. LPA identified client #4 did not have a current medical assessment on file. No physicians Report LIC 602A. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2024
Plan of Correction
1
2
3
4
Licensee/administrator will adhere to Title 22 80069.2 regulations and will ensure client #4 will have a current medical assessment done by 07/15/24. Proof of correction must be sent to LPA by due date 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: 06/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
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: ACOSTA FAMILY HOME II
FACILITY NUMBER: 198320282
VISIT DATE: 06/15/2024
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
LPA observed First Aid Kit was maintained. A working landline phone was operational. The last fire drill was conducted on 04/24/24. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current Surety Bond on file.

An audit of clients #1-#4 (C1-C4) service files and staff #1-#6 (S1-S6) personnel files were reviewed. Interviews with clients #1-#3 (C1-C3) were performed. The facility is current with CCL annual dues.

DEFICIENCIES:
Record audit/reviewed identified two staff #4 & staff #5 were not associated at this facility and is included on LIS 500 Personnel Report. According to administrator both staff are working at this facility without proper association and no LIC 9162 Criminal Clearance Background Transfer on file. LPA identified baseboard molding in bathroom #3 peeling from the wall and need to be repaired or replaced. LPA identified there is no designated back up qualified administrator on file. LPA identified staff #4 did not have a health screening LIC 503 on file and no proof of TB test results. LPA identified client #4 did not have a current medical assessment on file. No physicians Report LIC 602A.

ADVISORY - TECHNICAL VIOLATION
Client #4 (C4) is identified over the age of 60 years and will required a request from CCL Age Exception (Acceptance and Retention Limitations per Title 22 Regulation 85068.4).

According to the California Code of Regulations (Title 22, Division 6, Chapter 1), the following deficiencies has been observed and citation issued (ref. LIC 9099-D).

An exit interview was conducted with Anet Alegria and a copy of the report was provided.



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) are cleared. *

*IMMEDIATE CIVIL PENALTY*

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

DATE: 06/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5