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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600396
Report Date: 04/26/2024
Date Signed: 04/26/2024 01:46:06 PM

Document Has Been Signed on 04/26/2024 01:46 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:E. D. RESIDENTIAL CAREFACILITY NUMBER:
198600396
ADMINISTRATOR/
DIRECTOR:		DACOSTA, EVADNEY C.FACILITY TYPE:
735
ADDRESS:1244 WESTCHESTER PLACETELEPHONE:
(323) 734-4756
CITY:LOS ANGELESSTATE: CAZIP CODE:
90019
CAPACITY: 5CENSUS: 4DATE:
04/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Evadney DaCostaTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Alma Gonzalez conducted the required annual inspection. LPA met with Administrator Evadney DaCosta and discussed the purpose of today’s visit.

The facility is licensed to serve five (5) developmentally disabled clients (age 18-59) and is approved for 4 ambulatory and 1 nonambulatory. Nonambulatory room is located on the first floor. Currently, there are four (4) clients in placement, there are no clients who have a restricted health care condition. All clients residing at this facility receive case management services provided by Frank D Lanterman Regional Center.

LPA utilized the Compliance and Regulatory (CARE) tools for the visit today and observed the following:

Infection Control: Facility has an Infection Control Plan in place.

Physical Plant & Environment Safety: The facility is a two story home located in a residential neighborhood and consists of: First floor consists of the dining room, living room, kitchen, staff office, bathroom, relaxation room, and client dining area. Second Floor consists of: 4 bedrooms (one staff bedroom and 3 client rooms) and a recreation room. Physical plant inside and outside is in good repair. All client rooms were inspected and observed to have the required furniture such as bed frames, dressers, lamps and chairs. All bedrooms had sufficient lighting. Clients beds have the required linens which were in good condition at the time of the visit. Bathrooms are clean and operational and were observed to be within Title 22 regulations. Toilets and water faucets worked properly. Shower was free of mold/mildew, sufficient lighting throughout the facility, and sufficient toiletries are accessible/ available to clients. Water temperature measured at 111F*. Facility temperature was comfortable. LPA observed the facility to be clean and appropriately furnished with clear passageways inside and outside. First aid kit is fully stocked with manual, smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of

Refer to LIC 809C for the continuation of this report
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2024
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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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: E. D. RESIDENTIAL CARE
FACILITY NUMBER: 198600396
VISIT DATE: 04/26/2024
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water present. Medications are stored, locked and inaccessible to clients. Hazardous toxins and/or items are inaccessible to clients, fire extinguisher is fully charged. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards.

Operational Requirements: Staff are adhering to operational requirements. Fire Drills are conducted monthly, the last fire drill was conducted on 4/15/23. Emergency Disaster/ Earthquake Drills are conducted monthly and the last one was conducted on 4/20/23. Facility Administrator is adhering to operational requirements.

Staffing: There is sufficient staffing at the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records-Training: LPA reviewed staff files for Staff 1 (S1) through Staff 3 (S3). Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file.

Client Rights-Information: Client rights are posted and were also observed in client files.

Client Records-Incident Reports: LPA reviewed Client files for Client 1 (C1) through Client 4 (C4). Client files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Weight Record, Functional Capabilities Assessment, Consent For Medical Treatment, House Rules, Individual Program Plan, and Client Rights were observed.

Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. Cleaning supplies are kept away from the food preparation areas. The kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services: The medications are centrally stored and locked. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubble packed and delivered monthly.

Incidental Medical Services: Per Administrator, there are no clients with a restrictive health plan, no clients utilizing postural supports nor clients with prohibited health conditions.

Disaster Preparedness: The facility has an Emergency Disaster Plan (LIC610D/9 pages) in place.

No deficiencies noted. Exit interview and a copy of this report was provided to Administrator Evadney Dacosta.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2024
LIC809 (FAS) - (06/04)
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