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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601604
Report Date: 06/29/2024
Date Signed: 06/29/2024 11:57:47 AM

Document Has Been Signed on 06/29/2024 11:57 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:CALIFORNIA MENTOR - 256TH HOMEFACILITY NUMBER:
198601604
ADMINISTRATOR/
DIRECTOR:		MARGARITA NUNEZ RENTERIAFACILITY TYPE:
735
ADDRESS:1716 256TH STREETTELEPHONE:
(424) 263-4028
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY: 4CENSUS: 4DATE:
06/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:59 AM
MET WITH:Spencer CroasdaleTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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On 06/29/2024, Licensing Program Analyst (LPA) Antonine Richard, conducted an unannounced annual required visit using the new CARE Inspection Tool. LPA met with Spencer Croasdale Program Supervisor, and explained the purpose of today’s visit. The facility is licensed to operate for four (4) non-ambulatory developmentally disabled clients of between the ages of 18 through 59. Currently, the home has (4) clients. The clients are Harbor Regional Center clients. One of the four clients have a Restricted Health Care Condition and none are utilizing postural supports or protective devices.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) client rooms, two (2) bathrooms, a living area, a dining area, and kitchen. There is an outside patio area with ample seating and an umbrella used for shade. The laundry area is a room with a door and locked cabinets. There is a detached garage used for storage only.

LPA conducted a records review of (4) client records, (5) staff records, (4) clients Personal & Incidental Records and reviewed the facility disaster plan. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (4) Client Medication Administration Records and did not observe any discrepancies at the time of visit.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: CALIFORNIA MENTOR - 256TH HOME
FACILITY NUMBER: 198601604
VISIT DATE: 06/29/2024
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LPA and, Spencer Croasdale toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were clean and operational. The hot water temperature met Title 22 standards and measured at 117. 9 F degrees. A comfortable temperature was maintained in the facility.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharp objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. There are two (2) fire extinguishers fully charge located in the hallway near the front door and the back door. Smoke detectors and carbon monoxide were operable and in working condition. The last fire/emergency drill was conducted on 06/06/2024.

During the visit, LPA observed the facility infection control practices. LPA observed that the required postings were posted throughout the facility and the facility has a 60-day supply of Personal Protective Equipment (PPE).

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did observe deficiencies, and therefore citations were issued for personnel records. An exit interview was conducted. Appeal Rights, and a copy of this report was provided to Spencer Croasdale, Program Supervisor

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2024
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Document Has Been Signed on 06/29/2024 11:57 AM - It Cannot Be Edited


Created By: Antonine Richard On 06/29/2024 at 11:28 AM
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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: CALIFORNIA MENTOR - 256TH HOME
FACILITY NUMBER: 198601604

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
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: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 4 out of 5 employee files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2024
Plan of Correction
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Licensee shall submit documentation that the employee files have been updated with a health screening for all staff, Xiomata venegas, Pacheco Dulce, Roxana carranza, and Juarez Jacqueline . Email Proof to LPA antonine.richard@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
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 4 out of 5 employee files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2024
Plan of Correction
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Licensee shall submit documentation that the employee files have been updated with health screening with TB Test verification for all staff. Xiomara Venegas, Pacheco Dulce, Rosana Carranza,and Juarez Jacqueline. Email Proof to LPA Antonine.Richard@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:Eva M Alvarez
LICENSING EVALUATOR NAME:Antonine Richard
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2024


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