<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600462
Report Date: 05/02/2022
Date Signed: 05/02/2022 02:29:20 PM

Document Has Been Signed on 05/02/2022 02:29 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME:MEDING'S HOME CARE IIIFACILITY NUMBER:
198600462
ADMINISTRATOR:ROGELIO S. ROMEROFACILITY TYPE:
735
ADDRESS:1619 WEST 216TH STREETTELEPHONE:
(310) 830-3286
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 6CENSUS: 2DATE:
05/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:ROGELIO ROMERO/MARIO LOPEZTIME COMPLETED:
02:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA Lourdes Montoya conducted an unannounced annual visit on 5/2/2022 at 12:05 pm. Upon arriving at the facility, LPA met with Direct Support Professional (DSP) Mario Luis Lopez who assisted with the visit. The purpose of today’s visit was discussed with DSP. Licensee arrived later and joined the visit. The facility is licensed for six (6) clients, ambulatory only, prefers to serve developmentally disabled adults ages 18 thru 59 years. Harbor Regional Center refer level 3 clients to this facility. The facility annual fees are current during today’s visit.

LPA toured the single-story facility with DSP. This facility consists of two (2) resident bedrooms, one (1) staff bedroom, kitchen, dining area, living room, staff office, two (2) bathrooms (bathroom#2 for staff use only), laundry area, and garage. Currently, there are two (2) clients and two (2) staff present during today’s visit. Administrator's certificate expires 9/16/2022.

During the visit, LPA observed operable smoke detectors in bedrooms and hallways. One operable carbon monoxide detector located in the hallway next to the kitchen. One fire extinguisher last serviced on 3/21/2022 is located in the kitchen/dining area. The last facility fire drill was on 1/8/2022. LPA observed the facility to be sanitary and appropriately furnished at the time of visit. The kitchen was inspected and there is sufficient perishable and non-perishable food available.

There are no pools or bodies of water on the premises. There are no firearms on the premises and other dangerous weapons. Centrally stored medications are locked in a cabinet located in the kitchen. The first aid kit has all required supplies.



Report Continued in LIC 809-C
SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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
MONTERY PARK, CA 91754
FACILITY NAME: MEDING'S HOME CARE III
FACILITY NUMBER: 198600462
VISIT DATE: 05/02/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The facility has a written emergency disaster plan posted in the bulletin board. The facility is maintained at a comfortable temperature. LPA observed hot water temperature in the common bathroom measures 109.7 degrees Fahrenheit. There are working lights or lamps in each room at the time of visit. There is a grab bar for the toilet and shower used by clients. Shower has non-skid mat.

During the visit, LPA observed the following to be in compliance: facility's infection control practices; screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms; every staff was wearing a face covering; the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has a Mitigation Plan Report approved by CCLD.

Deficiencies were cited (see LIC 809D) from the California Code of Regulations, Title 22.

Exit interview conducted and appeal rights discussed. A copy of this report and appeal rights provided to Licensee Rogelio Romero.

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/02/2022 02:29 PM - It Cannot Be Edited


Created By: Lourdes Montoya On 05/02/2022 at 01:39 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 DR #100
MONTERY PARK, CA 91754

FACILITY NAME: MEDING'S HOME CARE III
FACILITY NUMBER: 198600462

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2022

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
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above. LPA observed a lysol spray on top of the sanitizing station/table at the facility entrance; clorox disenfecting wipes and lysol spray in the staff office; and comet cleaning powder in the clients' common bathroom. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2022
Plan of Correction
1
2
3
4
Licensee agreed to move all toxic items and store them in a locked cabinet. Licensee will send a proof of correction to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
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:Angela J Kendrick
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/02/2022 02:29 PM - It Cannot Be Edited


Created By: Lourdes Montoya On 05/02/2022 at 01:39 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 DR #100
MONTERY PARK, CA 91754

FACILITY NAME: MEDING'S HOME CARE III
FACILITY NUMBER: 198600462

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2022

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
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above. LPA observed a missing cabinet drawer in clients room #2. DSP stated the drawer was broken and needs to be fixed. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2022
Plan of Correction
1
2
3
4
Licensee agreed replaced the missing drawer and corrected the deficiency during the visit.
Type B
Section Cited
CCR
85087.2(b)
Outdoor Activity Space
(b) The outdoor activity area shall provide a shaded area, and shall be comfortable, and furnished for outdoor use.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above. LPA did not observe any outdoor furtniture for clients' outdoor activity use. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2022
Plan of Correction
1
2
3
4
Licensee agreed to put an outdoor seating furniture with a shade. Licensee will send a proof of correction to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.
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:Angela J Kendrick
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2022


LIC809 (FAS) - (06/04)
Page: 4 of 4