198600781-3-11-2022-11-AS-JCAS-CCETNW-20220311135326

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600781
Report Date: 03/11/2022
Date Signed: 03/11/2022 01:53:36 PM

Document Has Been Signed on 03/11/2022 01:53 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME:	DELIGHT SOME LAND		FACILITY NUMBER:	198600781
ADMINISTRATOR:	ALLEN D HAWKINS		FACILITY TYPE:	735
ADDRESS:	13313 ROSELLE AVENUE		TELEPHONE:	(310) 644-0420
CITY:	HAWTHORNE	STATE: CA	ZIP CODE:	90250
CAPACITY: 4		CENSUS: 2	DATE:	03/11/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:41 AM
MET WITH:	Allen Hawkins		TIME COMPLETED:	12:45 PM

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Licensing Program Analyst (LPA) Jey Cardenas conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA Cardenas met with administrator, Allen Hawkins and conducted a risk assessment. Based on the assessment, the facility is clear of Covid-19 infection. LPA verified that the facility has an approved mitigation plan report.

The facility is licensed for four (4) ambulatory developmentally disabled clients ages 18-59 years of age.

LPA and administrator both toured the inside and outside grounds of the facility. LPA reminded administrator to follow mitigation plan to ensure visitors are properly screened for Covid-19 symptoms and temperature checked.

The one-story residential house consists of (2) client bedrooms, (1) bathroom, living room, dinning room/ den, kitchen, staff room and an outdoor covered patio, backyard, a garage/ storage, and one storage shed. .

During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance. PPE supplies are readily available to staff, and an additional 30-day supply of PPE was observed. Sufficient paper, cleaning, and disinfecting supplies were observed. LPA Observed staff wear a face covering. LPA observed required postings throughout the facility.

All rooms were inspected. Bedrooms are private. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed.

Bathrooms were checked, sufficient liquid soap and paper towels were observed. Toilets and water faucets worked properly, grab bars were secure, the shower was free of mold/mildew. The water temperature measured at 117.9 degrees F in bathrooms. Comfortable temperature was maintained in the facility.

(Report continued on LIC 809C)

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: DELIGHT SOME LAND	FACILITY NUMBER: 198600781
	VISIT DATE: 03/11/2022

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LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. On 3/11/2022 LPA observed frozen food items taken out of the original packaging and stored in Ziplock plastic bags. Bags were not properly labeled with item and expiration dates. Knives and toxins were kept in a locked garage. Centrally stored medications were observed stored in their originally received containers and kept safe and locked and inaccessible to clients in care. The First Aid kit was available. Interconnected Carbon Monoxide and Smoke Detectors (connected) were tested. The facility (1) Fire Extinguisher was checked and found to be fully charged and accessible.

Outside grounds were toured, On 3/11/2022 LPA observed clutter all over the backyard; such as empty cans, wood pieces, etc yard was not clear of hazards.Living room was clutter with the office furniture and paperwork, boxes. Allen indicates that he is doing some minimal cosmetic work while the clients are out at program. Bodies of water were not observed.

Advisory Notes with technical assistance were issued.

1. LPA did not observe printed copies of CDSS PINs. Administrator stated summaries of PINs were not provided to residents/families/responsible parties.

2. License has not completed the N-95 Fit Testing requirement for all staff.
3. Ensure clients/ staff temperatures are taken and documented/ logged.
4, Ensure all visitors sign in, temp and screening is documented.

Deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted and appeal rights discussed. A copy of this report and appeal rights provided to Allen Hawkins.

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/11/2022 01:53 PM - It Cannot Be Edited

Created By: Jey Cardenas On 03/11/2022 at 11:26 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
MONTERY PARK, CA 91754

FACILITY NAME: DELIGHT SOME LAND	FACILITY NUMBER: 198600781
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above: On 3/11/2022 LPA observed backyard, livinroom, and den were full of clutter. Facility is getting cosmetic work completed and there were tools, paint, wood pieces lying in common areas.which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/25/2022
	Plan of Correction
1 2 3 4	Facility will declutter Livingroom area and backyard.

Type B

Section Cited

CCR

80076(a)(1)

Food Service

(a) In facilities providing meals to clients, the following shall apply: (1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan -Daily Food Guide for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above: On 3/11/2022 LPA observed freezer with various frozen food items in ziplock bags that were not properly labeled. which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/18/2022
	Plan of Correction
1 2 3 4	Facility will submit self certifation to LPA indicating facility food storing procedures when items are taken out of original packaging and stored in plastic bags.

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:

Angela J Kendrick

LICENSING EVALUATOR NAME:

Jey Cardenas

LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

LIC809 (FAS) - (06/04)

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