198600561-1-6-2023-11-AS-WGIS-CLQRBN-20221202115300

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600561
Report Date: 12/02/2022
Date Signed: 01/06/2023 04:23:31 PM

Document Has Been Signed on 01/06/2023 04:23 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:	JR RESIDENTIAL CARE		FACILITY NUMBER:	198600561
ADMINISTRATOR:	HARRISON, JANICE		FACILITY TYPE:	735
ADDRESS:	4565 WEST 167TH STREET		TELEPHONE:	(310) 542-2360
CITY:	LAWNDALE	STATE: CA	ZIP CODE:	90260
CAPACITY: 4		CENSUS: 4	DATE:	12/02/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:52 AM
MET WITH:	Janice Harrison		TIME COMPLETED:	11:45 AM

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

On 12/02/2022, Licensing Program Analyst (LPA) Wendy Gibbs conducted an unannounced required annual visit with a primary focus on infection control measures using the CARE inspection tool. Currently, there are (three) 3 ambulatory clients and one (1) non-ambulatory. LPA met with Administrator Janice Harrison and Nilda Ramos and toured the inside and outside grounds of the facility.

Structure The facility is a single-story home in a residential neighborhood. There are four (4) bedroom, two (2) bathroom, living room, kitchen and attached garage, which is inaccessible to residents.

Physical Plant LPA walked the grounds. There is a shaded seating area available in the backyard for residents. All walkways were free of obstructions, hazards and debris. LPA observed no bodies of water.

Bedrooms LPA inspected all three resident bedrooms and the staff room. All bedrooms have the required furniture. There is a dresser, nightstand, bed and chair available for all clients. Ample closet space and lighting were observed in each room. All beds had a mattress cover, fitted sheets, blankets, comforter and pillow.

Bathrooms LPA inspected both bathrooms and found that they were in good working order. Toilets, faucets and showers were in good working condition. The showers were clean and free of mildew or mold, they had secured grab bars, non-skid mats and shower chairs. There was an ample supply of hygiene products for the residents. The water temperature measured between 107.2-106.2 degrees Fahrenheit.

Linens & Hygiene LPA observed an ample supply of linens, blanket and comforters. There is additional hygiene supplies stored.

Kitchen All appliances were in good working condition. All cutleries were in good condition and there was an ample supply. LPA observed a 3-day supply of perishable food and a 10-day supply of nonperishable food. All knives and toxins were locked in a cabinet and inaccessible to residents. The water temperature measured 108.7 degrees Fahrenheit.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022

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 2

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: JR RESIDENTIAL CARE	FACILITY NUMBER: 198600561
	VISIT DATE: 12/02/2022

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

Common Areas Living room was clean and clear of obstructions. There was ample seating for all residents. There were activities for the residents. All doorways were clear.

Files LPA reviewed all resident file and found that they contained all required documentation. Also reviewed were three (3) staff files and they were found to contain all the required documentation and certification.

Medication LPA reviewed MARs and medication for all residents. Centrally stored medications were observed stored in their originally received containers and kept safe and locked and inaccessible to residents.

Safety LPA observed all smoke/carbon monoxide detectors to be in good working order. The fire extinguisher was fully charged and last serviced on 02/03/22. The last fire drill was on 11/15/22. All necessary signs were posted. All exits were marked. First aid kit was inspected and contained all the necessary items.

Infection Control During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance; visitors log with Covid-19 screening and temperature log was present. LPAs temperature was taken and logged before entry, also was asked covid screening questions. PPE supplies are readily available to staff, and an additional 30-day supply of PPE is stored in the garage; sufficient paper, cleaning, and disinfecting supplies were observed. LPA observed all staff wearing masks. LPA observed required postings throughout the facility.

LPA reviewed Surety Bond which is good through 2025.

No deficiencies were cited during this visit.

An exit interview was conducted, and a copy of this report was provided to the Administrator.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2