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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600006
Report Date: 04/18/2022
Date Signed: 04/20/2022 09:02:04 AM

Document Has Been Signed on 04/20/2022 09:02 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:MILLMONT HOMEFACILITY NUMBER:
198600006
ADMINISTRATOR:ABRAJANO,GARYFACILITY TYPE:
735
ADDRESS:1118 E. MILLMONT STREETTELEPHONE:
(310) 631-1952
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY: 4CENSUS: 2DATE:
04/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Mariciel CalindTIME COMPLETED:
02:45 PM
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On 04/18/22, at 3:22 pm, Licensing Program Analyst (LPA) Susan Campos conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with DSP Mariciel Calind, and explained the purpose of today’s visit. This facility is licensed to serve (4) non-ambulatory Developmentally Disabled Adults age 18 – 59. A level 4 D home vendorized with the South Central Los Angeles Regional Center. Currently, the home has (2) ambulatory clients. LPA inspected the inside/outside facility grounds. The last fire drill was conducted on 4/6/22. LPA conducted a review of Medication Administration Record (MAR) and medications. All medications and records are maintained in compliance with label instructions. All records are maintained in order. This home consists of three (3) client bedrooms, one staff bedroom, two bathrooms, living room/ office area, family room, kitchen/ dining area, backyard shaded area, and washer/dryer located in the garage.

LPA and Ms. Calind toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The hot water temperature measured 111.7 degrees Fahrenheit. A comfortable temperature of 75 degrees Fahrenheit was maintained in the facility.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly. Fire extinguishers were charged, smoke detectors and carbon monoxide were operable. A review of Medication Administration Records (MAR) was maintained in order and accurate.

Evaluation Report Continues on LIC 809-C

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Susan Campos
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2022
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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: MILLMONT HOME
FACILITY NUMBER: 198600006
VISIT DATE: 04/18/2022
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During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff and residents were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

No deficiencies were cited during this inspection visit.

An exit interview was conducted and a copy of this report was provided to DSP Mariciel Calind.

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Susan Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022
LIC809 (FAS) - (06/04)
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