198601564-10-13-2022-11-AS-ASOO-CK6LSA-20221013090026

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601564
Report Date: 09/25/2022
Date Signed: 10/13/2022 09:00:34 AM

Document Has Been Signed on 10/13/2022 09:00 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
MONTEREY PARK, CA 91754

FACILITY NAME:	LIVING LIFE		FACILITY NUMBER:	198601564
ADMINISTRATOR:	CHANDLER, BRENDA		FACILITY TYPE:	735
ADDRESS:	4645 W 129TH ST		TELEPHONE:	(310) 722-7541
CITY:	HAWTHORNE	STATE: CA	ZIP CODE:	90250
CAPACITY: 3		CENSUS: 3	DATE:	09/25/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Brenda Chandler, Administrator		TIME COMPLETED:	12:30 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

Licensing Program Analyst (LPA) Ana Soto conducted an unannounced Annual required and infection control visit to the above facility. LPA was met by Bernadeth, LVN and later met with Brenda Chandler and the purpose of today’s visit was explained.

There are currently (3) residents from West-side Regional Center in the facility. (0) residents are ambulatory, (3) are non-ambulatory, (0) bedridden. The facility is a single-story beige stucco structure located in a residential neighborhood. It consists (3) bedrooms, (2) full bathrooms, central air/heat, shaded front porch with ramp, shaded back porch with ramp, gazebo, laundry area and a detached 2 car garage.

LPA and Bernadeth toured the entire facility inside and out. Documents are posted as mandated. Bedrooms 1-3 are occupied by residents and contain the mandated furniture. There are no staff rooms. The (2) bathrooms have grab bars and non-skid mats and are clean and operational. First aid kit is fully stocked with manual; smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to residents. (1) Resident file along with medications are current. (1) Staff file is current. Ample supply of perishable and nonperishable food, hot water temperature is (116.4) degrees Fahrenheit, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents, (2) fire extinguisher are fully charged. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in good repair.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2022

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 2

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
MONTEREY PARK, CA 91754

FACILITY NAME: LIVING LIFE	FACILITY NUMBER: 198601564
	VISIT DATE: 09/25/2022

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

During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry & visitors and temperatures are logged and checked, sanitizer/soap, paper towels, in all the bathrooms and additional sanitation supplies are stored in the garage. LPA observed staff wearing masks, resident private rooms will be converted to isolation rooms (if needed,) trash cans with lids, cart for PPE’s, mitigation plan posted and/or in folder, Fit testing completed for staff, and required postings throughout the facility. Visitor designated area, facility has internet & computer for residents to use, resident’s temperatures are checked and logged (three X a day). Emergency contacts updated and posted; PPE's are enough for 30 days. All residents and staff are vaccinated and boosted.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

No technical Advisory (TA) issued.

An exit interview conducted with Brenda Chandler, Administrator.

Due to technical difficulties (printer not working) reports provided via email.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2