198601427-2-26-2023-11-AS-PSCT-CPEQTN-20230226112726

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601427
Report Date: 02/26/2023
Date Signed: 02/26/2023 11:27:34 AM

Document Has Been Signed on 02/26/2023 11:27 AM - 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:	PEAK PERFORMANCE SPECIALIZED HOME		FACILITY NUMBER:	198601427
ADMINISTRATOR:	VANESSA REED		FACILITY TYPE:	735
ADDRESS:	4513 3RD AVE		TELEPHONE:	(323) 369-3987
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90043
CAPACITY: 4		CENSUS: 3	DATE:	02/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:42 AM
MET WITH:	Dorine Nunez		TIME COMPLETED:	12:00 PM

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On 02/26/23, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced visit to this facility for the purpose of an annual visit with a primary focus on infection control measures. LPA was met by Dorine Nunez, DSP, and the purpose of today’s visit was explained. The facility is licensed to serve 4 developmentally disabled clients (age 18-59). There are three (3) clients’ currently in care. The facilities annual fees are current.
As part of the inspection, my primary focus was on infection control. LPA observed the facility’s infection control practices: LPA observed a sanitizing station at the facility entrance. LPA’s temperature was taken at the entrance of the facility, and it was logged in the logbook. PPE supplies are readily available to staff and residents, and additional supplies are stored. Sufficient paper, cleaning, and disinfecting supplies were observed. The facility has the mandated COVID infection control posters.

The facility is located in a residential area. It is a single-story facility which includes four (4) client bedrooms, two (2) consumer bathrooms, living room, dining room, kitchen and laundry room, outside covered patio area. LPA observed that the front and back yard were clean, free of debris, and had no bodies of water present.

Continued on LIC809-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2023

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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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: PEAK PERFORMANCE SPECIALIZED HOME	FACILITY NUMBER: 198601427
	VISIT DATE: 02/26/2023

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LPA toured the facility with Dorine Nunez. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational.

The water temperature measured 110.9 F. A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is an enough perishable and non-perishable food available which is stored properly. Fire extinguisher was charged, smoke/carbon monoxide detectors were operable.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations (Located in common areas and restrooms). LPA observed staff and residents were wearing face coverings, an isolation room and required postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing (www.cdss.ca.gov) Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

During today’s visit there were no deficiencies observed.

Exit interview held and copy of the facility evaluation report was provided to Dorine Nunez, DSP.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2023

LIC809 (FAS) - (06/04)

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