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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600768
Report Date: 01/09/2025
Date Signed: 01/09/2025 02:58:32 PM

Document Has Been Signed on 01/09/2025 02:58 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:MISS DAISY'S ADULT RESIDENTIALFACILITY NUMBER:
198600768
ADMINISTRATOR/
DIRECTOR:		BETTY BROWNFACILITY TYPE:
735
ADDRESS:1654 WEST 51ST PLACETELEPHONE:
(323) 296-7390
CITY:LOS ANGELESSTATE: CAZIP CODE:
90062
CAPACITY: 6CENSUS: 4DATE:
01/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:04 AM
MET WITH:Betty BrownTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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On 1/9/25, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced Annual inspection visit to the above facility. LPA was met by Licensee, Betty Brown and the purpose of today’s visit was explained. The facility is licensed to serve six (6) ambulatory adults ages 18-59. There are currently four (4) clients in placement.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: House one (1) is a primary house for the administrator and her daughter. (Building one 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 secured. Clients only use the family room in the primary home. Clients reside in the 2nd house area behind the primary home. The second house includes three bedrooms, a bathroom and utility area. Two residents share two bedrooms. A separate enclosed building area contains a kitchen and dining room area.

LPA Gonzalez and Licensee Betty Brown toured the physical plant inside and out. There were no bodies of water or obstructions on the premises. All rooms were inspected, bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each client comfortably. Bathrooms are operational and observed to be within Title 22 regulations. The facility was observed to be appropriately furnished at the time of visit. A comfortable temperature was maintained in the facility.

The kitchen was inspected and observed to be within Title 22 regulations. Sufficient perishable and non-perishable food supply was maintained adequately. All sharps, toxins, cleaning solutions, and hazardous items, were securely locked and inaccessible to clients. A review of Medication Administration Records was maintained in order and accurate.

Continued on LIC809-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2025
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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: MISS DAISY'S ADULT RESIDENTIAL
FACILITY NUMBER: 198600768
VISIT DATE: 01/09/2025
NARRATIVE
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The facility has a landline telephone on-site in working condition. Smoke detectors and carbon monoxide detectors were operational and working properly. Fire extinguisher was fully charged. A stocked First Aid kit along with manual was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards.

During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents. There are 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. The facility has an approved CCLD Mitigation Plan.

Deficiencies were cited during the inspection, see LIC809-D.



An exit interview was conducted, and a copy of Report and Appeal Rights was provided to Licensee Betty Brown.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/09/2025 02:58 PM - It Cannot Be Edited


Created By: Elvira Gonzalez On 01/09/2025 at 12:38 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: MISS DAISY'S ADULT RESIDENTIAL
FACILITY NUMBER: 198600768

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and records reviewed, the licensee did not comply with the section cited above in [3] out of [3] staff files reviewed were missing their First Aid certificate, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/23/2025
Plan of Correction
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The administrator will submit proof of completed First Aid/CPR training for all staff to the department by email at Elvira.Gonzalez@DSS.CA.GOV by 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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2025


LIC809 (FAS) - (06/04)
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