198320428-1-24-2024-11-AS-DESA-CZSSF2-20240124124938

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320428
Report Date: 01/24/2024
Date Signed: 01/24/2024 12:49:51 PM

Document Has Been Signed on 01/24/2024 12:49 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:	INDALO HOMES		FACILITY NUMBER:	198320428
ADMINISTRATOR:	GAREL-JONES, IVAN		FACILITY TYPE:	740
ADDRESS:	1201 PEARL STREET		TELEPHONE:	(310) 392-2469
CITY:	SANTA MONICA	STATE: CA	ZIP CODE:	90405
CAPACITY:	6	CENSUS: 0	DATE:	01/24/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:09 AM
MET WITH:	Ivan Garel-Jones, Applicant		TIME COMPLETED:	01:00 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 01/24/2024 Licensing Program Analysts (LPA) David España conducted announced visit to this facility. LPA was greeted by applicant Ivan Garel-Jones and explained the purpose of today’s pre-licensing inspection visit. An application was submitted to CCLD on 09/28/2023 in the initial license application for a residential facility for the elderly, ages 60 years and above. The applicant requested a capacity of six (6) individuals, of which six (6) are non-ambulatory, and one (1) bedridden. Structure: The facility is a four (4) bedroom, three and half (3 -1/2) bathroom, one story home with a one (ADU) backhouse (i.e., bedroom #4) situated in a residential neighborhood. The home includes a living, dining, kitchen, and laundry area. The living room did include a fireplace. The living area included sectional seating. the kitchen has a refrigerator and stove. The rear exterior is fenced throughout. the passageways, walkways, and steps are free from obstructions. Evaluation Report Continues.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 5

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: INDALO HOMES	FACILITY NUMBER: 198320428
	VISIT DATE: 01/24/2024

NARRATIVE

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Bedrooms Residents:
The facility had four (4) bedrooms for residents. There are four (4) bedrooms for non-ambulatory residents and (1) of the bedrooms specific for the bedridden. All rooms include a full, queen, and twin-size bed, one (1) chair, one (1) nightstand, and one (1) table lamp. All bedrooms are equipped with a ceiling light. All rooms had a dresser, which complies with the requirement of 8 cubic feet of space. All rooms had closets for ample storage.
Bedrooms Staff:
There is no bedroom designated for live-in staff.
Bathrooms:
The facility has three and half (3 1-2) bathrooms. Bathrooms are accessible in all rooms. All bathrooms have a working toilet, washbasin, and shower with grab bars and non-skid mats.
Linens & Hygiene Supplies:
Beds have the required linen supplies which include pillowcases, mattress pads, fitted sheets, blankets, and bedspreads. An adequate supply of linen is stored in the hall closet inside the bedrooms.
Emergency Phone Numbers, Exit Plan & Menu:
Emergency phone numbers. The exit plan and menu are posted and readily available for review throughout the home. There are two (2) fire extinguisher located in the kitchen mounted on the wall. A telephone line is available in the kitchen, living, and dining rooms (telephone is housed in the living).
Evaluation Report Continues.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024

LIC809 (FAS) - (06/04)

Page: 2 of 5

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: INDALO HOMES	FACILITY NUMBER: 198320428
	VISIT DATE: 01/24/2024

NARRATIVE

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Emergency supplies and Personal Protective Equipment supplies are stored in the kitchen. The applicant as an approved Infection Control Plan on file
Food Service:
Dishes, cups, and flatware are stored in the kitchen cabinets, inspected, and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in a locked kitchen drawer. Food supply is adequately stored in kitchen cabinets and consists of the canned goods. The kitchen counters also had small appliances.
Smoke Detectors:
Smoke and carbon monoxide detectors throughout the interior space. Hardwired smoke detectors in all four (4) bedrooms and hallways. Carbon monoxide is located in the hallway.
Toxins:
All toxins are locked and stored under the kitchen sink cabinet.
Appliances:
Stove burners, oven, microwave, washer, and dryer are working. The kitchen counters also had small appliances which includes a blender, toaster, electric can opener, and coffee maker. There are two (2) refrigerators in the facility. The refrigerator measured a temperature of at least 40 degrees Fahrenheit for appropriate food storage. The facility is equipped with central heaters and air conditioning systems.
Water Temperature:
The water temperature is 120 degrees Fahrenheit throughout the kitchen and bathrooms. Evaluation Report Continues.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024

LIC809 (FAS) - (06/04)

Page: 3 of 5

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: INDALO HOMES	FACILITY NUMBER: 198320428
	VISIT DATE: 01/24/2024

NARRATIVE

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Medications, First-Aid Kit & Book:
A first aid kit is stored in the medication cabinet inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze, and locked and inaccessible to residents. The resident's medications will be stored in the same medication cabinet locked in the office area and inaccessible.
Resident & Staff Files:
The applicant is not handling the cash resources for residents. Records of staff and residents will be stored in a cabinet in the office area.
Reading Material, Games, Equipment & Materials:
The facility has board games, books, magazines, and other recreational materials for the resident's use all stored in the living room.
Pool/Jacuzzi & Pets:
There is no jacuzzi, or pool in the fenced area. There is one (1) resident pet cat.
Fire clearance:
A Fire Clearance inspection was conducted on 10/26/23 approved for a capacity for six (6) non-ambulatory, and one (1) bedridden.
Component III:
LPA España conducted the Pre-Licensing inspection along with the information provided about how to operate the facility within substantial compliance with Component III PowerPoint.
LPA España did observe one correction:
Missing first aid manual (Placed order to arrive 01/26/2024) Evaluation Report Continues.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024

LIC809 (FAS) - (06/04)

Page: 4 of 5

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: INDALO HOMES	FACILITY NUMBER: 198320428
	VISIT DATE: 01/24/2024

NARRATIVE

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An exit interview was conducted, and a copy of this report has been furnished to the applicant Ivan Garel-Jones. LPA España will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.

END OF REPORT

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024

LIC809 (FAS) - (06/04)

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