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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600723
Report Date: 08/21/2022
Date Signed: 08/23/2022 11:11:15 AM

Document Has Been Signed on 08/23/2022 11:11 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:VAUGHN LIVING SERVICESFACILITY NUMBER:
198600723
ADMINISTRATOR:VAUGHN SR., DAVIDFACILITY TYPE:
735
ADDRESS:2516 WEST 80TH STREETTELEPHONE:
(323) 752-5226
CITY:INGLEWOODSTATE: CAZIP CODE:
90305
CAPACITY: 4CENSUS: 3DATE:
08/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:48 PM
MET WITH:David Vaughn Sr, AdministratorTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ana Soto conducted an unannounced Annual inspection visit and infection control inspection to the above facility. LPA was met by David Vaughn Senior, Administrator and the purpose of today’s visit was explained.

There are currently (3) West-side Regional Center consumers in placement. All (3) clients are ambulatory. (0) non-ambulatory. The facility is a single-story structure located in a residential neighborhood. It consists of the following: 3 bedrooms, 2 bathrooms, living room, kitchen, dining room, shaded area, indoor and outdoor activity area, laundry area next to kitchen, and a detached garage.

LPA and Administrator toured the entire facility inside and out. Documents are posted as mandated by the DPH and CCLD. Bedrooms #1 & #2 are occupied by clients and contain the mandated furniture. Bedroom #3 is a staff bedroom. Bathrooms #1 has a broken toilet that does not flush and water leaking. The wall that holds the bathtub faucet needs repair, it has water damage and paint is chipped and coming up, no hot water in bathroom #1 sink faucet. Bathroom #2 is a staff bathroom. Kitchen lower cabinets are broken, paint is chipped, drawers do not close, 2 kitchen light fixtures do not work. The floor space and wall next to laundry equipment needs repair, floor need cleaning and wall needs cleaning and/or painting. The kitchen faucet broken, under kitchen sink water damage to floor and doors do not close. Smoke detectors and carbon monoxide detector comply and are operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to clients. 1 staff file is not current (needs current CPR and CPI cards), 1 resident file is not current (needs Physician's report and current IPP, medications were current. The water temperature is at 105 degrees. A comfortable temperature is maintained in the facility. Ample supply of perishable and nonperishable food, linens and personal hygiene supplies are adequate, hazardous toxins and/or items are inaccessible to clients, (1) fire extinguishers is fully charged. First Aid kit complete and has no manual. Exit, front and back yard are free of debris and/or hazards. The facility is in good repair.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE: DATE: 08/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2022
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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Document Has Been Signed on 08/23/2022 11:11 AM - It Cannot Be Edited


Created By: Ana Soto On 08/21/2022 at 01:52 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: VAUGHN LIVING SERVICES
FACILITY NUMBER: 198600723

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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80087(a)The facility shall be clean, safe, sanitary and in good repair at all times for the safety....... This was not met as evidence by: Based on Bathrooms #1 has a broken toilet that does not flush and water leaking. The wall that holds the bathtub faucet needs repair, it has water damage and paint is chipped and coming up. Which poses a potential health and hazard risk for all persons in care.
POC Due Date: 09/01/2022
Plan of Correction
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Facility will make repairs and provide photos of repairs to LPA by or on POC due date.
Section Cited
Deficient Practice Statement
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80076(a)(19) All equipment, fixed or mobile, dishes, and utensils shall be kept clean and maintained in safe condition. This was not met as evidence by: Based on Kitchen lower cabinets are broken, paint is chipped, drawers do not close, 2 kitchen light fixtures do not work. The floor space and wall next to laundry equipment needs repair, floor need cleaning and wall needs cleaning and/or painting. The kitchen faucet broken, under kitchen sink water damage to floor and doors do not close. Which poses a potential health and hazard risk for all persons in care.
POC Due Date: 09/01/2022
Plan of Correction
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Facility will make repairs and provide photos of repairs to LPA by or on 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:Janae Hammond
LICENSING EVALUATOR NAME:Ana Soto
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2022


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Document Has Been Signed on 08/23/2022 11:11 AM - It Cannot Be Edited


Created By: Ana Soto On 08/21/2022 at 03:02 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: VAUGHN LIVING SERVICES
FACILITY NUMBER: 198600723

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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80088(e)Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. This was not met as evidence by: Based on, no hot water in bathroom #1 sink faucet. Which poses a potential health and safety risk for all pesons in care.
POC Due Date: 09/01/2022
Plan of Correction
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Facility will send picture of fixed faucet with hot water temperature reading to LPA on or before POC due date.
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:Ana Soto
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2022


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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
MONTEREY PARK, CA 91754
FACILITY NAME: VAUGHN LIVING SERVICES
FACILITY NUMBER: 198600723
VISIT DATE: 08/21/2022
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During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry & visitors and temperatures are logged and checked, no sanitizer, soap, no paper towels, in the bathroom and additional sanitation supplies are stored in the garage. LPA observed staff and residents wearing masks, resident private rooms will be converted to isolation rooms (if needed) and shared room will be relocated if needed. Trash cans with lids, cart for PPE’s, no mitigation plan posted and/or in binder, Fit testing not completed for staff, and required postings throughout the facility. Visitor designated area, facility has internet & IPAD for residents to use, resident’s temperatures are checked and logged (once a day). No Emergency contacts updated and posted; PPE's are enough for 30 days. No pins (CCLD) posted for clients to review.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued a citation.

Technical Advisories (TA's) issued. No fit testing completed for staff, Mitigation Plan needs to be posted and/or in binder at facility. No emergency contact posted, No pins posted for clients to review.



An exit interview was conducted with David Vaughn Sr. Administrator, and a hard copy was provided along with Appeal Rights.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2022
LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 08/23/2022 11:11 AM - It Cannot Be Edited


Created By: Ana Soto On 08/21/2022 at 02:41 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: VAUGHN LIVING SERVICES
FACILITY NUMBER: 198600723

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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80069(b)(1)Such assessment shall be performed by a licensed physician, or designee, who is also a licensed professional...This was not met as evidence by: Based on 1 resident file is not current (needs Physician's report . Which poses a potential health and safety risk for all persons in care.
POC Due Date: 09/01/2022
Plan of Correction
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Facility will send copy of current Physician's report for C#1 to LPA on or before POC due date.
Section Cited
Deficient Practice Statement
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85165(f)(7)Current first aid certification and current certification in the use of cardiopulmonary resuscitation (CPR). and current CPI. This was not met as evidenced by: Based on 1 staff file is not current (needs current CPR and CPI cards) Which poses a potential health and safety risk for all persons in care.
POC Due Date: 09/01/2022
Plan of Correction
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Facility will send copy of S#1 current and completed trainings for both CPR & CPI cards, to LPA on or before 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:Janae Hammond
LICENSING EVALUATOR NAME:Ana Soto
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2022


LIC809 (FAS) - (06/04)
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