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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320286
Report Date: 04/13/2023
Date Signed: 04/13/2023 02:31:20 PM

Document Has Been Signed on 04/13/2023 02:31 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:ACOSTA FAMILY HOME IFACILITY NUMBER:
198320286
ADMINISTRATOR:ACOSTA, ASHLEYFACILITY TYPE:
735
ADDRESS:1540 EAST CYRENE DRIVETELEPHONE:
(310) 997-5615
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY: 4CENSUS: 3DATE:
04/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:01 AM
MET WITH:Ashley AcostaTIME COMPLETED:
02:50 PM
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On 04/13/23, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with the Ashley Acosta, Administrator, and the purpose of today’s visit was explained. The facility is licensed to serve for (4) ambulatory (developmentally disabled or Mentally Ill) adults ages 18 through 59. Currently, the home has (3) clients. The clients are South Central Los Angeles Regional Center and Harbor Regional Center clients. None the clients have Restricted Health Care Conditions; and none are utilizing postural supports or protective devices. The facilities annual fees are due on 04/19/23, in the amount of $454.00.

The home consists of 6 bedrooms and 4 bathrooms (3 client bedrooms, 2 full bathrooms, and 3 staff rooms, and 2 staff bathroom). Facility is a two-story house in a residential neighborhood. The facility is a tan stucco structure with a floor plan which includes living room, dining room, kitchen, family den, activity/ theater/ laundry/ storage room.

LPA conducted a records review of 3 client records, 2 staff records, 2 clients Personal & Incidental Records and reviewed the facility disaster plan. All client & Staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed 3 Client Medication Administration Records and did not observe any discrepancies at the time of visit. The last fire/emergency drill was conducted on 03/02/23.

Report continued on LIC809-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2023
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: ACOSTA FAMILY HOME I
FACILITY NUMBER: 198320286
VISIT DATE: 04/13/2023
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At 11:30am LPA and Ms. Acosta toured the inside and outside of the facility. All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting was observed , plenty of dresser and closet space was observed. Walls and floors were clean and in good repair. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly. Shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature properly measured between 105-120F.

Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide detector was observed and operational. Smoke detectors were working properly, fire extinguishers were fully charged, toxins and knifes were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Outside grounds were toured and no bodies of water were observed. Exits/ Walkways around the home were free of debris and hazards.

During the visit, LPA observed the following to be complying: the facility's infection control practices; screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms; the facility has a 60-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has a Mitigation Plan Report approved by CCLD.

The following advisory/technical assistance were issued.

The licensee shall ensure that personnel records are maintained in compliance with title 22. The staff file was missing a criminal records statement.

During today’s visit LPA did not observe any deficiencies.

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Ashley Acosta, Administrator.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023
LIC809 (FAS) - (06/04)
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