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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320352
Report Date: 02/01/2024
Date Signed: 02/01/2024 04:27:11 PM

Document Has Been Signed on 02/01/2024 04:27 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:MOORE FAMILY HOME, LLCFACILITY NUMBER:
198320352
ADMINISTRATOR:MOORE, JAMESFACILITY TYPE:
735
ADDRESS:238 W 231ST STREETTELEPHONE:
(310) 835-3082
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 4CENSUS: 4DATE:
02/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:James MooreTIME COMPLETED:
04:30 PM
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On 02/01/24, Licensing Program Analysts (LPAs) Ernand Dabuet and Sparkle Day conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with licensee and administrator James and Jill Moore. LPAs explained the purpose of the visit. The facility is licensed for (4) ambulatory adults ages 18-59 years of ages. Currently, the home has (4) clients. They are consumers of Harbor Regional Center.

The facility is a two-story structure located in a residential neighborhood. It consists of the following: three (3) clients' rooms, two (2) common bathrooms, (2) staff rooms, a living area, a dining area, a kitchen, a den, and an outside patio area.

LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were stocked during the visit. Bathrooms were operational. The water temperature measured 107 - 110 degrees F. A comfortable temperature of 72 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, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. A fire extinguisher was charged, and smoke detectors and carbon monoxide were operable. A review of the Medication Records Administration (MAR) was observed to be maintained in order and accurately. A working landline telephone was available and operable.

Evaluation Report continues LIC 9099-C
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/01/2024
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: MOORE FAMILY HOME, LLC
FACILITY NUMBER: 198320352
VISIT DATE: 02/01/2024
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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.

An audit of clients #1-#4 (C1-C4) service records and staff #1-#4 (S1-S4) personnel records revealed to be complete. Interviews conducted with (2) staff and (4) clients. A review of client's P&I found to be maintained in order and accurate. The facility has a current surety bond coverage. The facility has a current liability insurance 02/21/23 – 02/21/24. The facility is current on CCL annual dues.

No deficiencies cited during this inspection visit.

An exit interview conducted with Jill Moore and a copy of the report is provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024
LIC809 (FAS) - (06/04)
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