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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601565
Report Date: 11/08/2022
Date Signed: 11/08/2022 02:52:24 PM

Document Has Been Signed on 11/08/2022 02:52 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SENWOOD RESIDENTIAL CARE HOMEFACILITY NUMBER:
198601565
ADMINISTRATOR:SHIELA ANA S. FABIANFACILITY TYPE:
735
ADDRESS:11606 SENWOOD STREETTELEPHONE:
(562) 864-4799
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 4CENSUS: 4DATE:
11/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator Sheila FabianTIME COMPLETED:
03:06 PM
NARRATIVE
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On 11/08/22 at 12:00 p.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced visit for the purpose of conducting the required annual inspection. On today's visit LPA met with Staff #1 (S1) and explained the reason for the visit. Administrator Shiela Ana Fabian was contacted via phone and explained the reason for the visit. Administrator arrived at 12: 50 p.m. and assisted with the rest of the visit.

The facility is licensed to serve 4 clients between the age of 18 and 59 years old, with 1 Non-ambulatory and 3 Ambulatory. The facility is vendored through Harbor Regional Center. The facility is a single-story building in a residential area, with a kitchen, dining room/office space, living room, 4 bedrooms, 1 staff bedroom, 1 client bathroom, 1 staff bathroom, garage, backyard with shaded area and a detached house allocated for administrator. Fire extinguisher observed kitchen fully charged. There are smoke detectors/ Carbon monoxide located throughout the facility, tested and operational.



LPAs discussed infection control practices with administrator, toured the facility inside and out, reviewed food supply, reviewed staff files, and reviewed resident medications.

Report continued 809c
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2022
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SENWOOD RESIDENTIAL CARE HOME
FACILITY NUMBER: 198601565
VISIT DATE: 11/08/2022
NARRATIVE
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Bedrooms have the required furniture including bedframes, dressers, lamps, and chairs. Beds have the required linen and the linen is in good condition. Passageways and exits are free of obstruction. LPA toured the kitchen and observed 7 days of perishables and 2 days nonperishable. During the visit LPA observed knives and cleaning solutions unlocked in the kitchen. S1 locked the items during the visit. The front and backyard are well maintained. The resident bathrooms are clean, and showers have non-skid materials. The hot water temperature measured at 101.3 degrees F, which is below the regulated temperature of 105-120 degrees F. The facility temperature at the time the visit was comfortable. There is sufficient lighting throughout the facility. LPA observed a sufficient supply of PPE in the garage. Infection control signs were observed throughout the facility. Medications reviewed for all clients and appears to be given as prescribed. Facility file reviewed revealed administrator certificate # 6002001735 expire 4/20/2023. Last emergency disaster drill 11/01/22.

Pursuant to Title 22 code of regulations, the following deficiencies were cited (refer to LIC 809-D): Exit Interview Conducted with licensee / Appeal Rights Provided / A Copy of the Report Issued.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/08/2022 02:52 PM - It Cannot Be Edited


Created By: Jewel Baptiste On 11/08/2022 at 01:40 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SENWOOD RESIDENTIAL CARE HOME
FACILITY NUMBER: 198601565

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)(1)
Buildings and Grounds (g)(1)

Disinfectants, cleaning solutions, poisons,... other items that could pose danger if readily available to clients shall be stored where accessible to clients. (1) Storage areas for poisons, firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee failed to ensure knives and cleaning solutions are locked, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/09/2022
Plan of Correction
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This citation was corrected during the visit on 11/8/2022. S1 locked the items during the visit.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 11/08/2022 02:52 PM - It Cannot Be Edited


Created By: Jewel Baptiste On 11/08/2022 at 01:55 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SENWOOD RESIDENTIAL CARE HOME
FACILITY NUMBER: 198601565

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Furniture, Fixtures, Equipment and Supplies

Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maaintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients o attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, LPA tested water temperature in client bathroom and confirmed water temperature of 101.3, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2022
Plan of Correction
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Administrator will ensure water temperature is regulated between 105- 120 degrees F, and keep a log for 1 week. The log will be submitted to LPA for review by POC due date.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2022


LIC809 (FAS) - (06/04)
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