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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600723
Report Date: 11/19/2023
Date Signed: 11/19/2023 11:39:00 AM

Document Has Been Signed on 11/19/2023 11:39 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, 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:
11/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:David Vaughn Senior; AdministratorTIME COMPLETED:
12:15 PM
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On 11/19/2023 at 8:00 am Licensing Program Analyst (LPA) David España conducted an unannounced Required-1-year annual visit. Upon arrival at the facility, LPA España conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection (No COVID-19 cases). LPA verified that the facility has an approved mitigation plan report. LPA was granted access and allowed to enter the facility to conduct the inspection.

LPA was met by David Vaughn Senior; Administrator and the purpose of today’s visit was explained. Adult Residential Facilities (ARF) facility is licensed to serve 4 ambulatory, developmentally disabled adults 18 - 59 years only. 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 black mold back of toilet. Bathroom #2 is a staff bathroom. Smoke detectors and carbon monoxide detectors comply and are operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to clients. The water temperature measured at 105 degrees Fahrenheit. 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, (2) fire extinguishers are fully charged. First Aid kit complete and has manual. Exit, front and back yard are free of debris and/or hazards. The facility is in good repair. A comfortable temperature was maintained in the facility. Smoke detectors are interconnected and operational.LPA observed the facility was found to be appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents.Evaluation Report Continues on LIC 809C

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2023
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: VAUGHN LIVING SERVICES
FACILITY NUMBER: 198600723
VISIT DATE: 11/19/2023
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The kitchen was inspected and there is sufficient perishable and non-perishable food supplies. The facility has (2) fire extinguishers that were charged, smoke detectors, and carbon monoxide were operable.The facility conducted a Fire/Safety Drill on March 6, 2023. A working telephone (323) 752-5226 remains available. LPA reviewed three (3) out of three (3) clients records. LPA reviewed three (3) out of three (3) staff members records.

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

Based on observation, interview and record review, the licensee did not comply with the section cited above. Licensing Program Analyst (LPA) David España and David Vaughn Senior; Administrator observe two (2) out of three (3) at ages of above the acceptance and retention limits, which poses/posed a potential health, safety or personal rights risk to persons in care.



An exit interview was conducted with David Vaughn Sr. Administrator, and a hard copy was provided along with Appeal Rights.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2023
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Document Has Been Signed on 11/19/2023 11:39 AM - It Cannot Be Edited


Created By: David Espana On 11/19/2023 at 11:00 AM
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: 11/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.4(g)
(g) If acceptance or retention of an individual 60 years of age or older would result in the number of persons 60 years of age or older exceeding 50 percent of the census in facilities with a capacity of six or fewer clients, or 25 percent of the census in facilities with a capacity over six, the licensee must request an exception in order to accept or retain the individual. The exception request must be made in accordance with Section 80024. The documentation specified in Section 85068.4(c) must be submitted with the exception request.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above. Licensing Program Analyst (LPA) David España and David Vaughn Senior; Administrator observe two (2) out of three (3) at ages of above the acceptance and retention limits, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2023
Plan of Correction
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David Vaughn Senior; Administrator will address retention limits with the department and provide update to LPA at david.espana@dss.ca.gov.
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:Ulysses Coronel
LICENSING EVALUATOR NAME:David Espana
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2023


LIC809 (FAS) - (06/04)
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