198600586-9-6-2024-11-AS-SDAY-D8UP67-20240906110151

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600586
Report Date: 09/06/2024
Date Signed: 09/06/2024 11:02:05 AM

Document Has Been Signed on 09/06/2024 11:02 AM - 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

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: 2	DATE:	09/06/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Claudia Gamio		TIME COMPLETED:	11:20 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 09/06/24, Licensing Program Analyst (LPA) Sparkle Day conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with the Administrator Claudia Gamio and the purpose of today’s visit was explained. The facility is licensed to operate for (6) ambulatory Developmental Disabled Adults 18 through 59. The clients are all Harbor Regional Center consumers. Currently, the home has (2) clients. None the clients have Restricted Health Care Conditions, and none are utilizing postural supports or protective devices.

The Facility is a 2 story family home 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 shaded seating area, and a attached garage used for storage along with a washer and dryer.

LPA conducted a records review of (2) client records, (2) staff records, (2) clients Personal & Incidental Records and reviewed the facility disaster plan. All client & Staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (1) Client Medication Administration Records and did not observe any discrepancies at the time of visit.

At 9:20am LPA and Staff Blanca Arana toured the inside and outside of the facility. All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting was observed, plenty of dresser and closet space was observed. Walls and floors were clean and in good repair. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Toilets and water faucets worked properly. Shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature properly measured between 115F .

cont...809C

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Sparkle Day	TELEPHONE: (424) 544-1075
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

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 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: KINDWEILER HOME	FACILITY NUMBER: 198600586
	VISIT DATE: 09/06/2024

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

Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide detector was observed and operational. Smoke detectors were working properly, fire extinguishers were fully charged, toxins and knifes were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Outside grounds were toured and no bodies of water were observed. Exits/ Walkways around the home were free of debris and hazards

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).

During todays visit LPA observed the towel rack in the upstairs bathroom is broken and in need of repair.

Exit interview conducted with Claudia Gamio, Administrator and Appeals Rights was provided

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Sparkle Day	TELEPHONE: (424) 544-1075
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 09/06/2024 11:02 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: KINDWEILER HOME	FACILITY NUMBER: 198600586
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/06/2024

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 LPAs observation the licensee did not comply with the section cited above due to the towel rack is in need of repair in the upstairs bathroom. In which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/13/2024
	Plan of Correction
1 2 3 4	Licensee agrees to replace or repair towel rack in upstairs bathroom by POC date 9/13/24. Licensee will send picture of repair to LPA Day by POC date to; Sparkle.day@dss.ca.gov

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: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Sparkle Day	TELEPHONE: (424) 544-1075
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3