<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601003
Report Date: 02/10/2024
Date Signed: 02/10/2024 03:55:25 PM

Document Has Been Signed on 02/10/2024 03:55 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:ECF, ERAS HOUSE 2FACILITY NUMBER:
198601003
ADMINISTRATOR:DAN R. BOYLEFACILITY TYPE:
735
ADDRESS:4215 KEYSTONE AVENUETELEPHONE:
(310) 838-1109
CITY:CULVER CITYSTATE: CAZIP CODE:
90230
CAPACITY: 6CENSUS: 4DATE:
02/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:NICOLE PORTERTIME COMPLETED:
04:15 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 02/10/2024, Program Analyst (LPA) Antonine Richard made and unannounced inspection to ECF, Eras House 2 The purpose of today’s visit was to conduct the Required Annual inspection. During today’s visit, LPA Richard met with staff Eastland and was later joined by Administrator Nicole porter. The facility is licensed to serve six (6) developmentally disabled clients ages 18-59 years, ambulatory only. The facility currently has four (4) clients ambulatory clients. All clients are between the ages of 18-59.

As part of the inspection, LPA reviewed client records including P & I logs, staff records, medications and inspected the facility. LPA did not observe an Administrative Certificate on file for the facility. The last fire and earthquake drill were conducted on 12/19/2023.



LPA and staff toured the facility. The facility is a two story home located in a residential neighborhood. The home consists of: living room, dining room, kitchen, family room, TV room/Den, 6 bedrooms, 4 bathrooms, exercise room, shaded area. All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Walls and floors were clean and in good repair. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found not to be within Title 22 regulation. The hot water temperature tested between 131.3f and 131.9f. Toilets and water faucets worked properly. Showers were free of mold/mildew, adequate lighting, and sufficient toiletries accessible to clients.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
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: ECF, ERAS HOUSE 2
FACILITY NUMBER: 198601003
VISIT DATE: 02/10/2024
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
26
27
28
29
30
31
32
Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide detector was operational. Smoke detectors were working properly, fire extinguisher was fully charged and operational, toxins and sharps were locked and inaccessible to clients. Medications were all properly locked an inaccessible to clients, first aid kit was checked an in order, including manual. Outside grounds were toured and no bodies of water were observed. Exits/ Walkways around the home were free of debris and hazards.

Deficiencies and technical violation cited under California Code of Regulations, Title 22, Division 6, Chapter 1 on the attached LIC809-D.



Appeal Rights issued and discussed. Exit interview conducted and a copy of the report were provided to the administrator Nicole Porter.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 02/10/2024 03:55 PM - It Cannot Be Edited


Created By: Antonine Richard On 02/10/2024 at 03:06 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: ECF, ERAS HOUSE 2
FACILITY NUMBER: 198601003

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, nterview,record review, the licensee did not comply with the section cited above. In having hot water measure less than 105 to 120 degrees. LPA identified bathroom #1 and kitchen sink tested between 131. 5F and 131.8F degrees which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/11/2024
Plan of Correction
1
2
3
4
The Administrator agrees to have all the staff trained on checking the hot water temperature once a week, and recording the log. The administrator will submitted the plan of correction vial email to LPA. Antonine.Richard@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:Antonine Richard
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 02/10/2024 03:55 PM - It Cannot Be Edited


Created By: Antonine Richard On 02/10/2024 at 03:06 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: ECF, ERAS HOUSE 2
FACILITY NUMBER: 198601003

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(e)
Personnel Records
(e) All personnel records shall be maintained at the facility site.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in 5 out of 7staff missing 1st, LIC9052, LIC508, LIC503 TB, identifiers which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2024
Plan of Correction
1
2
3
4
The administrator agreed to have all the facility records on site and agreed to submit all the staff records via email to LPA. Antonine.Richard@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:Antonine Richard
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5