198320292-9-22-2023-11-AS-WGIS-CVWN79-20230922101221

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320292
Report Date: 06/30/2023
Date Signed: 09/22/2023 10:12:34 AM

Document Has Been Signed on 09/22/2023 10:12 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	ELIM ADULT CARE 1		FACILITY NUMBER:	198320292
ADMINISTRATOR:	AARON, RUTH		FACILITY TYPE:	735
ADDRESS:	7537 WEST 90TH STREET		TELEPHONE:	(310) 863-4955
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90045
CAPACITY: 4		CENSUS: 3	DATE:	06/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:25 AM
MET WITH:			TIME COMPLETED:	02:00 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 06/30/23, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced annual visit using the full Cares Tool at the facility listed above. LPA met with Direct Support Professional, Jason Darensburg, and the purpose of the visit was explained. We were later joined by Lead Direct Support Professional, Lonnie Turner. Currently there are three (3) Residents residing at the home and all residents were at day program during time of visit. Structure The facility is a single-story home in a residential neighborhood. The home has four (4) bedrooms, two (2) bathrooms, living room, family room, kitchen, dining room, attached garage, and outside shaded patio activity area. There is a fireplace in the living room that has a screen over it. Staff stated they do not use the fireplace. Physical Plant LPA toured the inside and outside of the facility with staff. The outside patio is accessible to clients. There are three (3) seating areas, with tables and chairs. One table is under a covered patio, and another has an umbrella. There is a workout area in an additional covered patio area for clients use. There were no bodies of water observed. LPA observed all exits and walkways around the home to be clean, clear, and free of obstructions, debris and hazards. All gates open easily from the inside for a quick evacuation. Bedrooms LPA inspected all four (4) bedrooms. All bedrooms were observed to have the required furniture including a bed, chair, dresser, night stand, and storage space for clients belongings. All beds were observed to have the required linens including mattress cover, fitted sheets, blanket, comforter, and pillows. All bedrooms had ample lighting. The walls and floors were observed to be clean and in good repair. Bathrooms LPA inspected both bathrooms. LPA found bathrooms to be within Title 22 regulation. The bathroom fixtures were clean, in good repair, and working properly. Nonskid mats were observed in the shower and bathtub. Toilets were in good working repair. LPA observed ample lighting in both bathrooms. The water temperature measured between 111.3-degrees and 115.9-degrees Fahrenheit. Linens & Hygiene In a cabinet in the bathroom, LPA observed an ample supply of hygiene products for clients, including shampoo, body wash, lotion, toothpaste, mouth wash, etc. In the hall cupboard, LPA observed an ample supply of sheets, blankets, comforters, and towels. Continued on LIC809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023

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: ELIM ADULT CARE 1	FACILITY NUMBER: 198320292
	VISIT DATE: 06/30/2023

NARRATIVE

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Kitchen LPA toured the kitchen and found it to be clean and in good repair. LPA observed all appliances including stove, oven, dishwasher, microwave and refrigerator to be working properly. LPA observed all cutleries, pots, and pans to be in good repair. LPA observed a 3-day supply of perishable foods and a 7-day supply of non-perishable foods labeled and stored properly. All cleaning supplies are secured in garage and are inaccessible to clients. All knives and other sharps are secured in a locked cabinet in the kitchen and are inaccessible to clients. The water temperature measured 113.8-degrees Fahrenheit.
Common Rooms In the dining room, LPA observed a table and chairs to accommodate all clients. In the living room, LPA observed a large L-shaped couch to accommodate all clients comfortably. In the family room are two (2) couches to accommodate all clients comfortably. LPA observed activities available for clients. All rooms were observed to be clean and in good repair. All rooms were observed to have ample lighting. All halls and walkways were observed to be clean, clear, and free of obstructions and hazards. The home was maintained at a comfortable temperature.
Safety Smoke detectors/carbon monoxide detectors were tested and fully operable. LPA observed two (2) additional carbon monoxide detectors in the hallway by the bedrooms and in the living room. LPA observed a fully charged fire extinguisher, mounted on the wall in the kitchen. The last emergency drill was conducted on 04/25/23. LPA reviewed the facilities emergency disaster plan that was posted. All exits are clearly marked. LPA inspected the First Aid kit and found it contained the required items and a manual. The home is equipped with a security alarm system that informs staff when a door or window is opened. All required documents are posted on a board in the family room. There are no firearms or ammunition stored on the premises.
Infection Control Upon entry all staff, clients, and visitors are screened. Temperatures are taken and logged upon entry. At the entrance and is a sanitizing station. LPA observed a 30-day supply of PPEs and staff stated an additional supply is available at the main office. LPA observed all required and recommended infection control signs posted throughout the facility.
Medications LPA reviewed centrally stored medications for all three (3) clients. LPA observed all medications to be in their original containers. LPA matched all medications to the MARs. All medications are secured in a locked cabinet in the kitchen and are inaccessible to clients.
Files LPA reviewed all three (3) client files and found they contained the required documents. LPA reviewed the client P&I records, Plan of Operation, and licensing reports for the past 12 months. LPA received a copy of the facilities Admission Policies, and Surety Bond. LPA has pictures of the facilities floor

Continued on LIC809-c

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023

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: ELIM ADULT CARE 1	FACILITY NUMBER: 198320292
	VISIT DATE: 06/30/2023

NARRATIVE

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plan, register of clients, personnel report, Emergency Disaster Plan, License, Personal Rights, activity schedule, meal menu, and Fire Clearance. Staff files were not reviewed due to them being at the main office and Licensee was not available to attend.
Interviews LPA interviewed 1 staff who was at the facility. Staff was able to answer all questions regarding procedure, policy and personal rights, LPA was unable to interview clients due to them being at day program.

LPA will return to conduct file reviews for Administrator and Staff.

There were no deficiencies cited during today’s visit.
An exit interview was conducted with Lonnie Turner, and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023

LIC809 (FAS) - (06/04)

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