198600454-1-18-2023-11-AS-PSCT-CN7RQY-20230118121419

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600454
Report Date: 01/18/2023
Date Signed: 01/18/2023 12:14:27 PM

Document Has Been Signed on 01/18/2023 12:14 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	OLIVE'S HOME		FACILITY NUMBER:	198600454
ADMINISTRATOR:	HARRIS, JO		FACILITY TYPE:	735
ADDRESS:	20020 BROADACRES AVENUE		TELEPHONE:	(310) 604-6010
CITY:	CARSON	STATE: CA	ZIP CODE:	90746
CAPACITY: 6		CENSUS: 4	DATE:	01/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Rizalie Bondoc		TIME COMPLETED:	01:00 PM

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On 01/18/23, at 11:15 am, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA was met by Rizalie Bondoc, staff, and the purpose of the visit was explained. The facilities annual fees are due as of 01/18/2023, in the amount of $454.00.

This facility is licensed to serve 6 (4) Ambulatory, (2) Non-Ambulatory Developmentally Disabled adults ages 18 to 59 years old. There are currently four residents in the facility. The facility is a single-story structure located in a residential neighborhood. The residential home has the following areas: 4 bedrooms (1 bedroom for staff), 2 bathrooms, living/ office desk, kitchen, dining room, two backyard patio and front porch. Staff/resident files, and medication were in a locked cabinet.

As part of the inspection, my primary focus was on infection control. LPA observed the facility’s infection control practices: LPA observed a sanitizing station at the facility entrance. PPE supplies are readily available to staff and residents, and additional supplies are stored. Sufficient paper, cleaning, and disinfecting supplies were observed. The facility has the mandated COVID infection control posters.

LPA Scott and Ms. Bondoc 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 facilities hot water temperature measured 118.4 degrees Fahrenheit.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

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: OLIVE'S HOME	FACILITY NUMBER: 198600454
	VISIT DATE: 01/18/2023

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LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharp 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. Both fire extinguishers were charged, smoke detectors and carbon monoxide were operable. All disinfectants, toxins, knives, and cleaning solutions were locked and inaccessible to residents.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations (Located in common areas and restrooms). LPA observed staff was wearing face coverings, and the required postings were posted throughout the facility. LPA observed the facility has a 90-day supply of Personal Protective Equipment (PPE). LPA’s temperature was taken as well as instructions on where to sign in for the visitors logbook.

LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing (www.cdss.ca.gov) for Provider Informational Notices (PIN) and for any updates relating to COVID-19 guidance.

No deficiencies were cited during this inspection visit.

An exit interview was conducted, and a copy of the facility evaluation report was provided to Lead DSP Ms. Bondoc.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

LIC809 (FAS) - (06/04)

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