198601350-10-26-2023-11-AS-DESA-CWYUU7-20231026155305

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601350
Report Date: 10/26/2023
Date Signed: 10/26/2023 03:53:19 PM

Document Has Been Signed on 10/26/2023 03:53 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	DIXON HOME		FACILITY NUMBER:	198601350
ADMINISTRATOR:	DENISE BRENKLIN		FACILITY TYPE:	735
ADDRESS:	4333 W 58TH PLACE		TELEPHONE:	(323) 294-1942
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90043
CAPACITY: 4		CENSUS: 3	DATE:	10/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:07 AM
MET WITH:	Administrator, Denise Brenklint		TIME COMPLETED:	04:35 PM

NARRATIVE

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On 10/26/2023 at 8:00 am Licensing Program Analyst (LPA) David España conducted an unannounced 1-year Annual visit to the facility. Upon arriving at the facility, LPA met with Caregiver, Dantenette Brenklin and Administrator, Denise Brenklin who assisted with the visit. The purpose of today’s visit was discussed. Upon arrival at the facility, LPA conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection. LPA was granted access and allowed to enter the facility to conduct inspections.

The Adult Residential Facility is licensed for four (4) clients of which two (2) may be non-ambulatory or ambulatory. Currently, there are three (3) South Central Los Angeles Regional Center (SCLARC) clients present during today’s visit. LPA met with Caregiver, and toured the inside and outside grounds of the facility.LPA observed a few required postings throughout the facility.The last fire drill was conducted on 09/28/2023 at 3:20 pm with all clients participating. All two bedrooms (2) were inspected.

One (1) rooms is shared and room #2 is has only one individual. Bed linen were sufficient in amount, mattresses are in need bed covers, adequate lighting was provided, storage for client personal belongings was observed. Furniture in the living room observed to be in decent condition.There are no security bars or weapons on the premises. Client bathrooms were checked, toilets and water faucets worked properly.The water temperature measured at 110.0 F. A comfortable temperature was maintained in the facility. LPA toured the kitchen area and observed a 2-day supply of perishable and a 7-day of non-perishable food. Cleaning supplies were observed locked. Centrally stored medications were observed stored in their originally received containers and observed locked and inaccessible to residents in care. One fire extinguisher was observed in the kitchen area fully charged.

Outside grounds were toured, no bodies of water were observed. Walkways around the home were not clear of hazards. Common areas were observed in need of a deep cleaning; all doorways were free of obstruction. Continued on 809C

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

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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Document Has Been Signed on 10/26/2023 03:53 PM - It Cannot Be Edited

Created By: David Espana On 10/26/2023 at 02:32 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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: DIXON HOME	FACILITY NUMBER: 198601350
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1565(a)(5)

Other Provisions

(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (5) At least two appropriate shelter locations that can house or supervise, as applicable, individuals served by the facility during an evacuation. One of the locations shall be outside of the immediate area. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above. LPA España and Denise Brenklin did not observe updated LIC610D (i.e., 9 page LIC610), which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/03/2023
	Plan of Correction
1 2 3 4	The administrator will create a plan to ensure future compliance to Tite 22 Regulation 1565(a)(5) Disaster Preparedness Requirements. Proof of correction will be submitted to the department via email at David.espana@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:

David Espana

LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

LIC809 (FAS) - (06/04)

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Document is an Amendment of Original Document on 10/31/2023 04:16 PM

Created By: David Espana On 10/26/2023 at 02:50 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: DIXON HOME	FACILITY NUMBER: 198601350
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85066(a-c)

This requirement is not met as evidenced by: (a-c) In addition to Section 80066, the following shall apply. (b) A dated employee time schedule shall be developed at least monthly, shall be displayed conveniently for employee reference and shall contain the following information for each employee: (1) Name. (2) Job title. (3) Hours of work. (4) Days off. (c) The licensee shall maintain documentation that the administrator has met the certification requirements specified in Section 85064.2.
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above.During an interview and record review of S#1-S#4 with the Administrator, it was revealed that S#2 was missing Verification of training in first aid; S#3 was missing LIC 503; LIC 501; LIC 500; LIC 508; Verification of training in first aid; and Verification of education, experience, training. This poses a potential health and safety risk to residents in care. .
	POC Due Date: 11/03/2023
	Plan of Correction
1 2 3 4	The administrator will create a plan to ensure future compliance to Tite 22 Regulation 85066(a-c) Personnel Records. Proof of correction will be submitted to the department via email at David.espana@dss.ca.gov.

Type B

Section Cited

CCR

85095.5(2)(A-E)

This requirement is not met as evidenced by: Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products. These activities shall be completed, at a minimum, as follows: (A) Surfaces such as floors, chairs, toilets, sinks, counters and tabletops shall be cleaned… (B) Walls and window coverings in client care areas shall be dusted or cleaned on a regular schedule… (D) Facility items that cannot be disinfected shall be discarded immediately in an appropriate waste receptacle… (E) For a client's personal item(s) that cannot be disinfected, the licensee shall work with the client to mitigate human contact or transmission.
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, & record review, the licensee did not comply with the section cited above. During tour of facility with of S#1-S#2 and the Administrator, it was observed that room #2-bathroom vanity drawers were broken. LPA and S#2 observed room #2 closet without lighting. LPA and S#2 observed 95% of all window blinds broken. LPA and S#2 observed a backyard wooden door access to fire escape lane broken. This poses a potential health and safety risk to residents in care.
	POC Due Date: 11/26/2023
	Plan of Correction
1 2 3 4	The administrator will create a plan to ensure future compliance to Tite 22 Regulation 85095.5 (2)(A-E) Infection Control Requirements. Proof of correction will be submitted to the department via email at David.espana@dss.ca.gov.

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:

David Espana

LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

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: DIXON HOME	FACILITY NUMBER: 198601350
	VISIT DATE: 10/26/2023

NARRATIVE

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LPA conducted an audit of resident R#1-R#3 (R1-R3) files, and staff #1-#4 (S1-S4) personnel files.LPA conducted four (4) staff interviews.

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

There were deficiencies cited during this visit.

The following advisory notes were discussed with the Administrator/Licensee:

Physical Plant & Environmental Safety - Technical Violation: 80087(a)
Physical Plant & Environmental Safety - Technical Violation: 80088(f)(1)
Physical Plant & Environmental Safety - Technical Violation: 85088(c)(4)
Disaster Preparedness - Type B: 1565(a)(5)
Tite 22 Regulation 85066(a-c) Personnel Records.
Tite 22 Regulation 85095.5 (2)(A-E) Infection Control Requirements.

An exit interview was conducted, and a copy of this report was provided to Administrator, Denise Brenklin.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

LIC809 (FAS) - (06/04)

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