198601544-12-9-2023-11-AS-SLEO-CYCTZ6-20231209140951

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601544
Report Date: 12/09/2023
Date Signed: 12/09/2023 02:10:01 PM

Document Has Been Signed on 12/09/2023 02:10 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	WEBSTER HOME		FACILITY NUMBER:	198601544
ADMINISTRATOR:	MUHAMMAD, SHIRENA		FACILITY TYPE:	735
ADDRESS:	2326 WEBSTER AVENUE		TELEPHONE:	(562) 490-9800
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90810
CAPACITY: 3		CENSUS: 3	DATE:	12/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Shirena L Muhammad		TIME COMPLETED:	02:20 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 12/09/2023 at around 9:20 AM, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with the Administrator Shirena L. Muhammad. LPA explained the purpose of the visit and was accompanied by the Supervisor inside and outside the facility during this inspection. This facility is licensed to serve 3 non-ambulatory developmentally disabled adults ages 18 – 59 years. A total of 3 clients currently reside in this facility, of which 2 are non-ambulatory and 1 is an ambulatory adult. The Annual Licensing Fees are current. The facility is a one story house located in a residential street. The home consists of 3 client bedrooms, 2 bathrooms, 1 living/dining/kitchen area, 1 family room, 1 garage, and 1 backyard patio area with shaded seating. Outside grounds were toured and no bodies of water were observed. The patio furniture is under a shaded area and accessible to clients. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. LPA toured the kitchen area and observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and cleaning solutions were kept in a locked storage cabinet.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2023

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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: WEBSTER HOME	FACILITY NUMBER: 198601544
	VISIT DATE: 12/09/2023

NARRATIVE

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LPA observed that medications were safe, locked, and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Documents are posted as mandated. Last Disaster drill was conducted on 9/27/2023. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational. There are two fire extinguishers, one in the living room and the other in the family room; both fire extinguishers were last serviced on 08/02/2023. There are videoconferencing devices (laptops) dedicated for client use in the living room. LPA observed an unlocked cabinet with cleaning solutions in the back bathroom. The Supervisor immediately moved the cleaning supplies to a locked cabinet.

3 out of 3 client’s bedrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly. Adequate lighting and toiletries accessible to clients. LPA tested hot water temperature and it measured between 105 and 120 degrees Fahrenheit. This facility provides clients with hygiene products such as nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb.

5 staff records were reviewed, 5 out of 5 staff records had current First Aid Certificates, Criminal Record Clearances, Job Applications, and Trainings. 1 out of 5 staff records did not have a Tuberculosis Test.

3 client records were reviewed and, 3 out of 3 client records had Admission Agreement, Medical Assessments, Consent Forms, Weight Record, Emergency Information, Appraisal & Needs Service Plan, Tuberculosis Test, Centrally Stored Medication Destruction Record, and Personal Rights.

Deficiencies are being cited based on LPA observation and record review in accordance with the California Code of Regulations, Title 22, see LIC809D. A violation regarding Tuberculosis Test and cleaning solutions being easily accessible to clients in care.

An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Administrator.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/13/2023 03:16 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 12/13/2023 03:14 PM

Created By: Socorro Leandro On 12/09/2023 at 01:37 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: WEBSTER HOME	FACILITY NUMBER: 198601544
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having an unlocked cabinet with cleaning solutions in the bathroom, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/19/2023
	Plan of Correction
1 2 3 4	The Supervisor immediately moved cleaning solutions to a locked cabinet. The licensee will re-train staff on how to store potentially dangerours items/solutions to clients in care and email proof of correction to Socorro.Leandro@dss.ca.gov.

Type B

Section Cited

CCR

80066(a)(11)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 5 staff records not having a Tuberculosis test on file, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/02/2024
	Plan of Correction
1 2 3 4	The licensee will email Staff #5 Tuberculosis Test results to Socorro.Leandro@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:

Socorro Leandro

LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2023

LIC809 (FAS) - (06/04)

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