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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320286
Report Date: 03/27/2024
Date Signed: 03/27/2024 11:49:51 AM

Document Has Been Signed on 03/27/2024 11:49 AM - 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 IFACILITY NUMBER:
198320286
ADMINISTRATOR:ACOSTA, ASHLEYFACILITY TYPE:
735
ADDRESS:1540 EAST CYRENE DRIVETELEPHONE:
(310) 997-5615
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY: 4CENSUS: 3DATE:
03/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:13 AM
MET WITH:Ashley AcostaTIME COMPLETED:
12:00 PM
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On 03/27/24, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with 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 of the clients have Restricted Health Care Conditions; and none utilizes postural supports or protective devices. The facilities’ annual fees are due on 04/19/24, in the amount of $454.00.

The facility is a two-story structure located in a residential neighborhood. It consists of the following: three (3) client bedrooms, three (3) staff bedrooms, two (2) client bathrooms, two (2) staff bathrooms, dining room, living room, kitchen, activity room, laundry/ storage room, and an attached garage.

LPA conducted a records review of (3) client records, (2) staff records, (1) clients Personal & Incidental Records (only one receives P & I) 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.

At 09:30am, LPA and the administrator toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All resident rooms were checked. Beds and bedding were in good condition, adequate lighting provided, adequate storage for client personal belongings was observed. Walls and floors were 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 regulations. Toilets and water faucets worked properly. The shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature measured 118.6F and a comfortable temperature is maintained in the facility.

Report continued on LIC809-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE: DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2024
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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: ACOSTA FAMILY HOME I
FACILITY NUMBER: 198320286
VISIT DATE: 03/27/2024
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LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is enough perishable and non-perishable food available, which is stored properly. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The fire extinguishers were charged, and smoke/ carbon monoxide detectors were operable. The last fire/emergency drill was conducted on 02/01/2024.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents. LPA observed that sanitizing stations were in common areas and restrooms. LPA observed that the facility had the required postings, posted throughout the facility. LPA further observed the facility to have a 60-day supply of Personal Protective Equipment (PPE).

LPA advised the administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing (www.cdss.ca.gov) for Provider Informational Notices (PIN) and for any updates relating to COVID-19 guidance and other related issues.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

During today’s visit there were no deficiencies observed.

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: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024
LIC809 (FAS) - (06/04)
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