198600778-12-20-2023-11-AS-PBUR-CYPUKR-20231220143935

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600778
Report Date: 12/20/2023
Date Signed: 12/20/2023 02:40:52 PM

Document Has Been Signed on 12/20/2023 02:40 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	AHMEN RESIDENTIAL FACILITY		FACILITY NUMBER:	198600778
ADMINISTRATOR:	DEBRA ADEWALE		FACILITY TYPE:	735
ADDRESS:	9618 SOUTH 8TH AVENUE		TELEPHONE:	(323) 779-5324
CITY:	INGLEWOOD	STATE: CA	ZIP CODE:	90305
CAPACITY: 3		CENSUS: 3	DATE:	12/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:27 AM
MET WITH:	Marion Gibson and Antoinette Paul		TIME COMPLETED:	02:30 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	Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced Annual Required -1 Year visit with the primary focus on Infection Control measures and using the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA was properly screened for COVID-19 symptoms and temperature was checked. LPA Bunker met with Lead Staff Marion Gibson and Assistant Administrator Antoinette Paul and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved Mitigation Plan Report and Infection Control Report. There are currently three (3), Westside Regional Center consumers and one in placement. The facility's annual fees are current. The following 12 Domains will be observed and reviewed: Infection Control, Physical Plant & Environmental Safety, Operational Requirements, Staffing, Personnel Records-Training, Client Rights-Information, Client Records-Incident Reports, Food Service, Health-Related Services, Incidental Medical Services, Disaster Preparedness, and Emergency Intervention. "LPA Bunker will be using this tool and methods that have been developed to improve the efficiency and accuracy of the Department of Social Services' facility inspections." Lead Staff Marion and LPA Bunker toured the facility. The facility is a single-story family home located in a residential neighborhood. Which consists of, a living room, dining area, family room, kitchen, 3 bedrooms, 2 bathrooms, laundry room, office, detached garage, and an indoor/outdoor activity area. A shaded area furnished with outdoor patio furniture, including tables and chairs. Bedrooms #1-3 are designated as the client's bedrooms. Each bedroom has one client to a room. See continued LIC809-C page 2

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: AHMEN RESIDENTIAL FACILITY	FACILITY NUMBER: 198600778
	VISIT DATE: 12/20/2023

NARRATIVE

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Continued LIC 809-C page #2

LPA Bunker observed the facility’s infection control practices, screening protocols for residents and visitors, sanitizer, visitor log, and thermometer at the facility entrance. Logs of daily COVID-19 screening and temperature checks of clients and staff were available and updated. PPE supplies are readily available to staff, and an additional supply of Personal Protective Equipment (PPE) was observed. Sufficient liquid soap, paper goods, cleaning, and disinfecting supplies were observed. LPA observed staff wearing a face covering and social distancing.

Documents are posted as mandated on the wall in the kitchen and living room. The following Title 22 regulated areas were audited and found to be in compliance: Telephone: The facility telephones are working. Bedrooms: All bedrooms meet the required standards for furniture, safety, privacy, and comfort. The facility has an adequate linen supply. Bathrooms: The bathrooms are clean and operational, and provide necessary personal accommodations with non-skid surface mats ensuring safety and privacy. Kitchen and Food Service: The kitchen is adequately equipped for food preparation and service. A review of the food service revealed an ample supply of perishable and nonperishable food, stored appropriately. Medication Storage and Management: Medications are centrally stored in locked toolboxes in the kitchen. The medication log records and MAR are up-to-date, ensuring proper storage and documentation. Common Areas: The Living room, dining room, and common areas are well-maintained, free of potential hazards, and meet the cleanliness standards necessary for the safety and well-being of residents. Safety Equipment and Measures: The facility is equipped with a fully stocked first aid kit with manual, functional smoke and carbon monoxide detectors, and a properly charged fire extinguisher. The hot water temperature is measured at 120 degrees and is maintained within the standard range of 105-120 degrees Fahrenheit. Emergency Preparedness: All exit doors are in compliance, the client's bedroom windows are equipped with sliding window locks without thumbscrews, and the facility conducted a fire drill on September 05, 2023.

See continued LIC809-C page #3

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

LIC809 (FAS) - (06/04)

Page: 2 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: AHMEN RESIDENTIAL FACILITY	FACILITY NUMBER: 198600778
	VISIT DATE: 12/20/2023

NARRATIVE

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Continued LIC809-C page 3

Environmental Safety: The yard is free from debris and hazards, trash cans are covered, and no firearms or bodies of water are present on the premises. Hazardous items are kept inaccessible to clients. Staff Training: Staff members have received training on dependent adult and elder abuse reporting. Administrative Compliance: The Administrator's Certificate is current and compliance with HIV/TB requirements is also verified.

LPA Bunker advised the staff to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing website (cdss.ca.gov) for Provider Informational Notices (PIN) and any updates relating to COVID-19 guidance.

LPA Bunker provided staff with a copy of the facility evaluation reports.

There were no deficiencies cited.

Exit interview conducted

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

LIC809 (FAS) - (06/04)

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