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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320390
Report Date: 07/31/2024
Date Signed: 07/31/2024 11:06:41 AM

Document Has Been Signed on 07/31/2024 11:06 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:PERSON CENTERED OPTIONS IIFACILITY NUMBER:
198320390
ADMINISTRATOR/
DIRECTOR:		THOMPSON, TIKIFACILITY TYPE:
735
ADDRESS:1402 E. WASHINGTON STREETTELEPHONE:
(909) 904-2913
CITY:LONG BEACHSTATE: CAZIP CODE:
90805
CAPACITY: 3CENSUS: 2DATE:
07/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:31 AM
MET WITH:DSP Andre ThompsonTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
NARRATIVE
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On 07/31/24, Licensing Program Analyst (LPA) Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with DSP Andre Thompson as the purpose of the visit was explained. The facility is licensed to serve (3) ambulatory develop disabled clients ages 19-59 of which (1) may be non-ambulatory in bedroom #1. Current facility census is (2), clients are linked to the Harbor regional center. Facility fees are current.

The facility is a single-story structure located in a residential neighborhood and consists of the following: (4) bedrooms,(2) bathrooms, (1) bathroom is for staff, two (2) car garage that is used for storage space, living room, family room, staff work area, dining area, laundry room, kitchen, and a large backyard with a wheelchair ramp and a shaded sitting area.The facility is clean, sanitary, and in good repair. Client bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, shower was free of mold/mildew, and there are sufficient toiletries accessible to clients. The water temperature properly measured between 105-120 F.. A supply of perishable and non-perishable food was observed, toxins and knifes were stored and inaccessible to clients, no weapons nor bodies of water on the premises, exits and walkways are free of debris/hazards.

LPA conducted a records review of 2 client records, and 2 medication administration records, no discrepancies observed. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire was conducted on 07/26/24, fire extinguisher fully charged, carbon monoxide and smoke detectors are interconnected and operational.

Deficiencies cited on 809D page.

Exit interview conducted with DSP Andre Thompson, and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/31/2024
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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Document Has Been Signed on 07/31/2024 11:06 AM - It Cannot Be Edited


Created By: Lizeth Villegas On 07/31/2024 at 10:40 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: PERSON CENTERED OPTIONS II
FACILITY NUMBER: 198320390

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(c)(e)
80066 Personnnel records

All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. removal of records shall be subject to the following requirements:

All personnel records shall be maintained at the facility site and shall be available to the licensing agency for review.
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA Villegas was unable to review personnel records as records were located in a locked cabinet and inaccessible to staff on shift which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/07/2024
Plan of Correction
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Licensee to ensure staff on shift have access to records during normal business hours. LPA Villegas to conducted unaanounced visit to review personnel files and clear citation.
Type B
Section Cited
CCR
85088(e)(2)
85088 Fixtures, Furniture, Equipment and Supplies
Emergency lighting, which shall include at a minimum working flashlights or other battery-powered lighting, shall be maintained and readily available in areas accessible to clients and staff.

Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

Deficient Practice Statement
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Based on [(observation) the licensee did not comply with the section cited above as there are no nightlights maintained in the hallways which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/07/2024
Plan of Correction
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Licensee to purchase and place nightlights in hallways and passages to nonprivate bathrooms. Licensee to provide proof to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Janae Hammond
LICENSING EVALUATOR NAME:Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2024


LIC809 (FAS) - (06/04)
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