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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600375
Report Date: 01/13/2023
Date Signed: 01/13/2023 02:54:39 PM

Document Has Been Signed on 01/13/2023 02:54 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MOSAIC OF FRIENDS IIIFACILITY NUMBER:
198600375
ADMINISTRATOR:FLEETWOOD, MECHELLEFACILITY TYPE:
735
ADDRESS:13414 BARLIN AVENUETELEPHONE:
(562) 633-6848
CITY:DOWNEYSTATE: CAZIP CODE:
90242
CAPACITY: 5CENSUS: 4DATE:
01/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Facility Manager, Yvonne CaldwellTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced annual inspection focusing on the Infection Control Domain. LPA was allowed entry into this home by Richard Obilor (Direct Support Professional/DSP) and discussed the purpose of today's visit. The facility is approved to serve Developmentally Disabled adults ages 18-59, ambulatory only. There are 4 clients living in the facility. This single-story home contains three (3) bedrooms, two (2) bathrooms, a living room, sitting area/activity area, kitchen, dining area, backyard, and detached garage. DSP Uchenna Umeohana arrived at 12:55pm and the Facility Manager arrived at 2:20pm and assisted LPA with the inspection.

The following was observed/inspected:
  • The facility had a universal entrance screening area including a thermometer, PPE supplies, screening logs, and sign-in sheet. LPA observed DSP Richard Obilor not wearing a mask and did not screen LPA for covid upon entry.
  • There was only one(1) COVID-19 signage placed on the front door entrance..
  • Facility maintained a 30-day supply of PPE stored in the detached garage.
  • The laundry room is located inside the home and has cleaning supplies inaccessible to residents.
  • The kitchen was inspected. There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. All the appliances are clean and are working properly.
  • LPA observed the cabinet under the kitchen sink that was unlocked which contained hazardous chemicals, bleach and cleaning solutions.
  • Kitchen knives and sharps were locked in a cabinet and inaccessible to clients.
  • Hot water temperature was measured in kitchen and bathrooms and found to be within the required 105 - 120 degrees.


****REPORT CONTINUED ON LIC809-C*****
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2023
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MOSAIC OF FRIENDS III
FACILITY NUMBER: 198600375
VISIT DATE: 01/13/2023
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  • Clients bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, night stand, light, chair and sufficient closet space.
  • Bathrooms contained hygiene supplies including liquid soap, paper towels, and toilet paper but LPA observed that there are no covid-19 precaution/safety posters.
  • Medications were locked, centrally stored, and given as prescribed. Medications were reviewed for all clients and facility maintained a 30-day supply of medications.
  • The sitting/activity room has pads all over the floor due to the leak in the roof.
  • Dining room and living room are clean and have the required furniture. Furniture and group activities were spaced to encourage physical distancing.
  • LPA observed that the backyard did not have a shaded area but has a table and chairs. The backyard has been designated as the visitor area during the COVID-19 pandemic.
  • There is (1) fire extinguisher mounted on the wall near the laundry and dining areas. It was observed to be fully charged and last serviced on 6/05/2022.
  • There are cameras in the hallways, kitchen, front door, dining/living room and activity area. There were no cameras seen in private areas.
  • Smoke detectors/carbon monoxide detectors were present and operable.
  • Staff and Clients files were not reviewed during this visit.

Technical assistance issued on separate LIC9102 form. Deficiencies were cited, exit interview conducted, and copy of the report and appeals rights were provided to the Facility Manager, Yvonne Caldwell.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 01/13/2023 02:54 PM - It Cannot Be Edited


Created By: Bennette Pena On 01/13/2023 at 02:09 PM
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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MOSAIC OF FRIENDS III
FACILITY NUMBER: 198600375

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the facility manager did not comply with the section cited above in which LPA observed the cabinet under the kitchen sink to be unlocked which contained disinfectants, cleaning solutions, bleach and other hazardous items which poses an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 01/16/2023
Plan of Correction
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The Facility Manager removed the disinfectants, cleaning solutions, bleach and other hazardous items in a locked cabinet.The deficiency was corrected during LPA's visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2023


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 01/13/2023 02:54 PM - It Cannot Be Edited


Created By: Bennette Pena On 01/13/2023 at 02:09 PM
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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MOSAIC OF FRIENDS III
FACILITY NUMBER: 198600375

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the facility manager did not comply with the section cited above in which LPA observed that the roof in the sitting/activity area was leaking which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 01/27/2023
Plan of Correction
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Facility Manager will submit photos, service report and invoices/receipts from the roofing company to prove that the roof has been fixed.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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2
3
4
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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2023


LIC809 (FAS) - (06/04)
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