198600006-4-28-2023-11-AS-PSCT-CRBPBK-20230428111029

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600006
Report Date: 04/28/2023
Date Signed: 04/28/2023 11:10:38 AM

Document Has Been Signed on 04/28/2023 11:10 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	MILLMONT HOME		FACILITY NUMBER:	198600006
ADMINISTRATOR:	ABRAJANO,GARY		FACILITY TYPE:	735
ADDRESS:	1118 E. MILLMONT STREET		TELEPHONE:	(310) 631-1952
CITY:	CARSON	STATE: CA	ZIP CODE:	90746
CAPACITY: 4		CENSUS: 2	DATE:	04/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Maricel Caling		TIME COMPLETED:	11:31 AM

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On 04/28/23, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced annual required visit, using the full Care Inspection Tool. LPA met with DSP, Mariciel Caling and explained the purpose of today’s visit. This facility is licensed to serve (4) non-ambulatory Developmentally Disabled Adults aged 18 – 59. A level 4 D home vendorized with the South-Central Los Angeles Regional Center. Currently, the home has (2) ambulatory clients. The facilities annual fees are current for 2023.

LPA inspected the inside/outside facility grounds. 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. Caling 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 clients 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 116.6 degrees Fahrenheit. A comfortable temperature was maintained in the facility.

Evaluation Report Continues on LIC 809-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

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: MILLMONT HOME	FACILITY NUMBER: 198600006
	VISIT DATE: 04/28/2023

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LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for cleaning supplies, toxins, and sharps were stored and not accessible to clients. 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. The facility maintains meal and snack menus for the clients, as well as a different mix of activities to be utilized by the clients.

Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Client and staff files were reviewed. All staff are fingerprint cleared and associated to the facility and have documentation of the required trainings on file. Exits/ Walkways around the home were free of debris and hazards.

LPA conducted a records review of (2) client records, (2) staff records, (2) clients Personal & Incidental Records and reviewed the facility disaster plan. All client & staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (2) Client Medication Administration Records and did not observe any discrepancies at the time of visit. The last fire/emergency drill was performed on 4/10/2023.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors and staff. Additionally, LPA observed sanitizing stations in common areas and restrooms. LPA observed staff wearing face coverings, and that 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 Caling.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

LIC809 (FAS) - (06/04)

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