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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601457
Report Date: 04/22/2022
Date Signed: 04/26/2022 09:31:09 AM

Document Has Been Signed on 04/26/2022 09:31 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME:LEE ADULT HOMEFACILITY NUMBER:
198601457
ADMINISTRATOR:ANDREW J. LEEFACILITY TYPE:
735
ADDRESS:20121 GREVILLEA AVENUETELEPHONE:
(310) 877-9282
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY: 6CENSUS: 4DATE:
04/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:06 PM
MET WITH:DWAIN GRIFFITH TIME COMPLETED:
02:00 PM
NARRATIVE
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On 4/22/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced annual required inspection with a primary focus on Infection Control measures using the new CARE Inspection Tool.

Upon arriving at the facility, LPA called Administrator Andrew Lee and conducted a risk assessment. LPA met with DSP1 Dwain Griffith and explained the purpose of this visit. LPA was granted access and allowed to enter the facility to conduct an inspection. The facility is licensed to serve six (6) ambulatory clients, ages 18-59. Currently, there are four (4) clients and two (2) staff present during the visit. The facility’s annual fees are current during today’s visit. Clients are referred by the Harbor Regional Center.

LPA toured the single-story facility with DSP1 Griffith. The facility consists of four (4) client bedrooms, one (1) staff bedroom, two (2) bathrooms, kitchen, dining area, office area, living room, garage with a laundry room, and backyard patio.

The kitchen was inspected and there is at least a one week supply of nonperishable and two day supply of perishable foods. The facility is maintained at a comfortable temperature. Hot water temperature measures at 117.3 degrees Fahrenheit. There are working lights in each room to ensure safety and comfort for all clients in the facility. All outdoor and indoor passageways were free of obstructions. The clients have clean linen which includes blankets/bedspreads, top and bottom sheets, pillow cases, and mattress pads. First aid kit had the required items. The facility has a written emergency disaster plan located in the office area. This facility has one operable carbon monoxide detectors located in the hallway. There are no pools or bodies of water on the premises. There are no firearms on the premises and other dangerous weapons. The last facility fire drill was on 4/13/2022. Centrally stored medications are locked in a cabinet located in the dining area.

Report continued in LIC 809-C

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2022
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: LEE ADULT HOME
FACILITY NUMBER: 198601457
VISIT DATE: 04/22/2022
NARRATIVE
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During the visit, LPA observed the following to be in compliance: facility's infection control practices; screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms; every staff was wearing a face covering; the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has a Mitigation Plan Report approved by CCLD.

Deficiencies were cited.

Exit interview conducted and a copy of this report and appeal rights were provided to DSP1 Dwain Griffith.

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 04/26/2022 09:31 AM - It Cannot Be Edited


Created By: Lourdes Montoya On 04/22/2022 at 01:21 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
MONTERY PARK, CA 91754

FACILITY NAME: LEE ADULT HOME
FACILITY NUMBER: 198601457

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. LPA observed unlocked disinfectants and cleaning solutions (lysol, clorox, oven cleaner, zep disinfectant, etc) in the cabinets in the laundry room in the garage. DSP1 stated clients access the garage and utlize the fitness equipments. LPA observed the door to the laundry room from the garage has no locks as well as the cabinets where the disinfectants and cleaning solutions are stored. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/23/2022
Plan of Correction
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DSP1 agreed to install locks on the laundry door. DSP1 will submit a POC to lourdes.montoya@dss.ca.gov by the POC due date or text photos to 510-725-7918.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2022


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/26/2022 09:31 AM - It Cannot Be Edited


Created By: Lourdes Montoya On 04/22/2022 at 01:30 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
MONTERY PARK, CA 91754

FACILITY NAME: LEE ADULT HOME
FACILITY NUMBER: 198601457

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85087.2
(b) The outdoor activity area shall provide a shaded area, amd shall be comfortable and furnished for outdoor use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. LPA did not observe an umbrella or a shade for the outdoor dining set. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2022
Plan of Correction
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DSP1 Griffith agreed to buy an umbrella for the outdoor dining set. DSP1 will send a proof of correction to lourdes.montoya@dss.ca.gov or text photos to 510-725-7918 by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Angela J Kendrick
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2022


LIC809 (FAS) - (06/04)
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