198320335-3-10-2023-11-AS-AINZ-CPT4K7-20230310180948

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320335
Report Date: 03/09/2023
Date Signed: 03/10/2023 06:10:44 PM

Document Has Been Signed on 03/10/2023 06:10 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:	ATARAXIS HOMES #2		FACILITY NUMBER:	198320335
ADMINISTRATOR:	BUCKMAN, JAMES		FACILITY TYPE:	740
ADDRESS:	6536 SPRINGPARK AVE		TELEPHONE:	(424) 702-5686
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90056
CAPACITY: 6		CENSUS: 0	DATE:	03/09/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:12 AM
MET WITH:	James and Lori Buckman-Licensees		TIME COMPLETED:	11:15 AM

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On 3/9/23 Licensing Program Analysts (LPA) Alfonso Iniguez conducted a pre-licensing evaluation for an RCFE facility type. Today’s pre-licensing evaluation was conducted with authorized licensees: Lori and James Buckman.The licensee has applied for a license to serve (6) elderly residents ages 59 and older. The fire clearance is approved for (5) non-ambulatory and (1) bedridden residents. The licensee plans to advertise for Special Care Programs for Dementia Residents.A tour of the Kitchen, Dining Room, Living Room, (5) Bedrooms, (2) Bathrooms, Garage, Storage for all supplies, Back Yard with a fenced body of water and Patio with shaded area.

The following was observed during this visit:

MEDICATIONS

There is a locked centralized storage area for Resident medications.

PHYSICAL PLANT

Facility is clean, sanitary, and in good repair. Protective devices are in place. Indoor and outdoor passageways, stairways, open porches, and other areas of potential hazard are free of obstructions. All window screens are clean and in good repair. Facility temperature is between 68°F. degrees and 73°F. degrees. Open porches, and areas of potential hazard are well-lit. Smoke alarms operate properly. Carbon monoxide detectors operate properly.

BEDROOMS

No client bedroom is a passageway to another room, bath or toilet. There is a bed for each client with a mattress, mattress pad, bedsprings, and pillow(s) which are clean and in good repair.

Mattresses and pillows are flame-retardant. There is dresser and closet space for each client that includes at least two (2) drawers or eight (8) cubic feet of dresser space per client. There is a chair and lamp for each client and at least one (1) night stand per two (2) clients.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

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: ATARAXIS HOMES #2	FACILITY NUMBER: 198320335
	VISIT DATE: 03/09/2023

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BATHROOMS

There is at least one (2) toilet and washbasin per six (6) clients, family, and personnel. There is at least one (2) shower or bathtub per ten (10) clients, family, and personnel. Hot water temperature is 113° Fahrenheit. Bathroom is located near client bedrooms. There are night-lights in the hallways outside non-private bathrooms.

SUPPLIES

There are client personal hygiene supplies to include soap, toothpaste, toilet paper, and comb. There is a sufficient supply of clean linens to permit weekly changing or more of client top sheets, bottom sheets, bedspreads, blankets, pillowcases, mattress covers, bath towels, hand towels, and washcloths.

FOOD SERVICE

Dining room is near kitchen. Refrigerator(s) and freezer(s) are clean and large enough for the storage of at least two (2) days of perishable foods. Freezer is 0° Fahrenheit. Refrigerator is a maximum of 45° Fahrenheit. A seven (7) day supply of non-perishable food is present. There are sufficient amounts of tableware, tables, dishes, and utensils. There are sufficient amounts of equipment for the storage, preparation, and service of food. All equipment, dishes, and utensils are clean and well maintained. All kitchen, food storage, and preparation areas are clean.

RECORDS

There is confidential storage of personnel records at the facility. There is confidential storage of client records at the facility.

ADMINISTRATION

The emergency exiting plan and emergency phone numbers are posted. Client Personal Rights are posted. Posting both sides of the Personal Rights form LIC 613 meets this requirement. Facility Visiting Policy is posted. Licensing Complaint Poster is posted. There is space available for resident council meetings and resident council postings.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

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: ATARAXIS HOMES #2	FACILITY NUMBER: 198320335
	VISIT DATE: 03/09/2023

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ACTIVITIES

There are an outside and inside activity spaces with a shaded area and furnished for outdoor use. There is at least one common room available to clients for visitors. There are activity supplies to include board games and electronic gaming system.

MISCELLANEOUS

There are first-aid supplies to include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual. There is space and equipment for laundry. There is a space for clean linen storage and a separate space for soiled linen. There is an operating telephone available to clients. Emergency lighting and supplies to include flashlights with batteries.

PRE-LICENSING CHECKLIST

N/A

COMPONENT III provided during visit

Provided information about how to operate the facility within substantial compliance.

During the pre-licensing inspection there were no deficiencies observed.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

LIC809 (FAS) - (06/04)

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