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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600586
Report Date: 09/30/2023
Date Signed: 09/30/2023 05:33:45 PM

Document Has Been Signed on 09/30/2023 05:33 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:KINDWEILER HOMEFACILITY NUMBER:
198600586
ADMINISTRATOR:GAMIO, CLAUDIA V.FACILITY TYPE:
735
ADDRESS:272 EAST 213TH ST.TELEPHONE:
(310) 999-8666
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 6CENSUS: 3DATE:
09/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:47 AM
MET WITH:Claudia GamioTIME COMPLETED:
03:59 PM
NARRATIVE
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On 09/30/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Administrator Claudia Gamio. LPA explained the purpose of today’s visit. The facility is licensed to operate for (6) ambulatory Developmental Disable Adults 18 through 59. The clients are all Harbor Regional Center consumers.

The facility is a two-story structure located in a residential neighborhood. It consists of the following: (4) client's rooms, (2) bathroom, (2) staff room (1) staff bathroom, a living area, a dining area, a kitchen, an outside seating area, and a garage used for storage.

LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 109.2 degrees F. A comfortable temperature of 72 degrees F. was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to clients. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. A fire extinguisher was charged. The last Emergency Fire Drill was conducted on 09/03/23. A review of the Medication Records Administration (MAR) was observed to be maintained in place.

(Evaluation Report continues LIC 809-C)
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2023
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: KINDWEILER HOME
FACILITY NUMBER: 198600586
VISIT DATE: 09/30/2023
NARRATIVE
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and clients, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA observed First Aid Kit was maintained. A working landline phone was operational. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has a Surety Bond coverage expires 02/23/25.

An audit of clients #1-#3 (C1-C3) service files and staff #1-#3 (S1-S3) personnel files revealed to be complete. An audit of the client's P&I is maintained in order and complete. Interviews were conducted with (3) client and (1) staff. The facility has the current administrator's certification on file for Claudia Gamio 6067495735 - 8/15/2023 8/14/2025.

Deficiencies:
The following were observed/identified during physical inspection visit:
  • Bleach and cleaning supplies - Accessible to clients under kitchen sink (unlocked)
  • Expired Food Items: (3) Sweet Relish (5/31/22; 12/24/22; 12/08/15) (1) Parkay Butter (01/03/23)
  • (1) Hidden Valley Ranch (02/02/23) (1) Pace Picante Sauce (04/27/23)
  • (1) Quart of ice cream in freezer with no lid/cover.
  • Kitchen stove top - Need deep cleaning
  • Built-in Microwave Oven - Need deep cleaning
  • Bathroom #1 - Cabinet need to be repaired the on wall.
  • Bathroom #2 - No cabinet door (need to be repaired/replaced)
  • Bathroom #2 - No toilet paper holder (replaced/repaired)

According to the California Code of Regulations (Title 22, Division 6, Chapter 1 & 6), the following deficiencies has been observed and citation issued (ref. LIC 9099-D).

An exit interview conducted with Claudia Gamio and a copy of report and appeal rights provided.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 09/30/2023 05:33 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 09/30/2023 at 02:43 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
MONTEREY PARK, CA 91754

FACILITY NAME: KINDWEILER HOME
FACILITY NUMBER: 198600586

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2023

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
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Based on observation the licensee did not comply with the cited above. LPA at 2:46 pm identified bleach and other cleaning supplies under kitchen sink in unlocked cabinet. This violation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2023
Plan of Correction
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The licensee will ensure to maintain all hazardous items in locked storage an not accessible to clients. Proof of correction must be completed by due date: 10/01/23. (Corrected during visit and was removed from cabinet and stored in locked storage).
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/30/2023 05:33 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 09/30/2023 at 02:43 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
MONTEREY PARK, CA 91754

FACILITY NAME: KINDWEILER HOME
FACILITY NUMBER: 198600586

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2023

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
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Based on observation, the licensee did not comply with the section cited above. LPA identified (3) items: bathroom cabinet door missing; bathroom cabinet need to be replaced; no toilet paper holder. This violation which is a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/30/2023
Plan of Correction
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Licensee will ensure to conduct all the necessary repairs in bathroom #1 & bathroom #2. Bathroom cabinet replaced in #1 and replaced missing door in bathroom #2 and replace/repair toilet paper holder. Proof of correction must be sent to LPA by 10/30/23 via email: ernand.dabuet@dss.ca.gov
Type B
Section Cited
CCR
80076(a)(17)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (17) All kitchen, food preparation, and storage areas shall be kept clean, free of litter and rubbish, and measures shall be taken to keep all such areas free of rodents, and other vermin.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA identified stove top range and built in microwave oven required deep cleaning. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2023
Plan of Correction
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Licensee will ensure to keep all kitchen equipment and appliances clean and sanitary for use. Proof of correction must be sent to LPA by due date: 10/07/23 via email: ernand.dabuet@dss.ca.gov
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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 09/30/2023 05:33 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 09/30/2023 at 02:44 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
MONTEREY PARK, CA 91754

FACILITY NAME: KINDWEILER HOME
FACILITY NUMBER: 198600586

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80076(a)(18)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (18) All food shall be protected against contamination. Contaminated food shall be discarded immediately.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA identified (6) food items with expired dates and (1) ice cream container store in freezer without cover. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2023
Plan of Correction
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Licensee will ensure to that all food items are stored properly. Food items with expired dates must be discarded and food items must be stored in containers to protect against contamination. Proof of correction must be sent to LPA by due date: 10/07/23 via email: ernand.dabuet@dss.ca.gov - Correction made during visit. Food items were discarded.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2023


LIC809 (FAS) - (06/04)
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