198600768-12-27-2022-11-AS-MLEN-CMHP54-20221227100008

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600768
Report Date: 12/20/2022
Date Signed: 12/27/2022 10:01:03 AM

Document Has Been Signed on 12/27/2022 10:01 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:	MISS DAISY'S ADULT RESIDENTIAL		FACILITY NUMBER:	198600768
ADMINISTRATOR:	BETTY BROWN		FACILITY TYPE:	735
ADDRESS:	1654 WEST 51ST PLACE		TELEPHONE:	(323) 296-7390
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90062
CAPACITY: 6		CENSUS: 4	DATE:	12/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:36 AM
MET WITH:	Betty Brown - Licensee		TIME COMPLETED:	12:22 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 12/20/22, Licensing Program Analyst (LPA) Mario Leon conducted an unannounced annual required visit with a primary focus on infection control measures. LPA met with the licensee and administrator Betty Brown. LPA explained the purpose of today's visit. The facility is licensed to operate for six (6) ambulatory adults ages 18-59. The facility is a single-story structure located in a residential neighborhood. It consists of the following: a primary house for the administrator and her daughter in building one (1). Building one (1) includes a living room, dining room, kitchen, family room (clients use the family room) laundry room, three bedrooms (not for clients) and two bathrooms. One bedroom is for office use and has an enclosed closet with medications locked and inaccessible to clients. Clients only use the family room in the primary home. Clients reside in the second (2nd) house, in back of the primary home. The second house includes three bedrooms, a bathroom and utility area / dining room. Presently, the census fis four (4). Two residents share bedroom one (1) and one resident in each bedrooms two through three (2-3). A separate entryway / visitation area is shade with chairs and tables. There is also a shaded smoking area beside bedroom three (3), with chairs, in the back yard. The yard is free of debris/hazards, and there are covered trash cans present. Bathrooms are operational and within title 22 regulations, showing the water temperature at 110.4 F. There is a sufficient supply of perishable and non-perishable foods, stored properly. Two fire extinguishers and smoke detectors are operable and in compliance. See LIC809-C

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

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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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: MISS DAISY'S ADULT RESIDENTIAL	FACILITY NUMBER: 198600768
	VISIT DATE: 12/20/2022

NARRATIVE

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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 adequate condition. Lighting was provided, storage for client's personal belongings was observed. The facility was observed to be appropriately furnished at the time of visit.

Advisory Notes - Technical Assistance was issued, pleas see LIC9102.

DEFICIENCIES WERE CITED DURING THE INSPECTION, see LIC809-D.

LPA advised the licensee to continuously monitor the centers for disease control (CDC) website and Community Care Licensing Provider Informational Notices (PINs) for any updates relating to COVID-19 guidance.

An exit interview was conducted and a copy of this report was provided to Licensee Betty Brown.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/27/2023 02:34 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 04/27/2023 08:53 AM

Created By: Mario Leon On 12/20/2022 at 12:57 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: MISS DAISY'S ADULT RESIDENTIAL	FACILITY NUMBER: 198600768
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/20/2022

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
1 2 3 4	Based on LPAs observation, the licensee did not comply with the section cited above in storing cleaning detergents unlocked below the kitchen sink which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/30/2022
	Plan of Correction
1 2 3 4	LPA and Licensee have agreed that on, or prior to, the POC due date that the Licensee will submit media evidence (photo) of the correction to mario.leon@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:

Ulysses Coronel

LICENSING EVALUATOR NAME:

Mario Leon

LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

LIC809 (FAS) - (06/04)

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