198600586-8-25-2021-11-AS-EDAT-C68W5C-20210825165852

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600586
Report Date: 08/25/2021
Date Signed: 08/25/2021 05:00:24 PM

Document Has Been Signed on 08/25/2021 05:00 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:	KINDWEILER HOME		FACILITY NUMBER:	198600586
ADMINISTRATOR:	GAMIO, CLAUDIA V.		FACILITY TYPE:	735
ADDRESS:	272 EAST 213TH ST.		TELEPHONE:	(310) 999-8666
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY: 6		CENSUS: 4	DATE:	08/25/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:54 AM
MET WITH:	CLAUDIA GAMIO		TIME COMPLETED:	01:31 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	On 08/25/21, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with licensee and administrator Claudia Gamio. LPA explained the purpose of today’s visit. The facility is licensed to operate for six (6) ambulatory adults ages 18 through 59. The clients are Harbor Regional Center consumers. The facility is a two-story structure located in a residential neighborhood. It consists of the following: four (4) client's rooms, two (2) common bathrooms, living area, dining area, kitchen, and a garage. LPA 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 was provided, storage for client 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 operational. The water temperature measured 107.9. A comfortable temperature of 73 degrees was maintained in the facility. LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. The fire extinguishers were charged, smoke detectors and carbon monoxide were operable. A review of the Medication Records Administration (MAR) was complete and accurate. Evaluation Report Continues on LIC 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: KINDWEILER HOME	FACILITY NUMBER: 198600586
	VISIT DATE: 08/25/2021

NARRATIVE

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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff and resident temperature logs were reviewed. The facility has an approved Mitigation Plan on file with CCLD.

During the inspection, LPA observed the facility has not conducted an emergency disaster drill in the past six (6) months. LPA observed four (4) clients' bedding was missing mattress pads These act are in violation of Title 22, Division 6 Chapter 1.

Advisory Notes - Technical Assistance was issued, please see LIC9102-AN.

An exit interview was conducted and a copy of this report was provided to Claudia Gamio by email.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/25/2021 05:00 PM - It Cannot Be Edited

Created By: Ernand Dabuet On 08/25/2021 at 12:49 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: KINDWEILER HOME	FACILITY NUMBER: 198600586
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/25/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85088(c)(4)

Fixtures, Furniture, Equipment, and Supplies

(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (4) Clean linen in good repair, including lightweight, warm blankets and bedspreads; top and bottom bed sheets; pillow cases; mattress pads; rubber or plastic sheeting, when necessary; and bath towels, hand towels and wash cloths. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in [4] out of [4] [(beds ) did not have the required mattress pads, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/07/2021
	Plan of Correction
1 2 3 4	Licensee will ensure that the items listed under this deficiency have been corrected to ensure compliance with California Code of Regulations Title 22, Section 85088 and provide proof of correction to CCL by the POC due date: 09/07/21

Type B

Section Cited

CCR

80023(d)

Disaster & Mass Casualty Plan

(d) Disaster drills shall be conducted at least every six months. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in no current disaster drill have been conducted within the last six months, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/07/2021
	Plan of Correction
1 2 3 4	Licensee will ensure that the items listed under this deficiency have been corrected to ensure compliance with California Code of Regulations Title 22, Section 80023 and provide proof of correction to CCL by the POC due date: 09/07/21

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:

Eva M Alvarez

LICENSING EVALUATOR NAME:

Ernand Dabuet

LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021

LIC809 (FAS) - (06/04)

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