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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601621
Report Date: 07/10/2024
Date Signed: 07/10/2024 04:34:13 PM

Document Has Been Signed on 07/10/2024 04:34 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:246 VAN ZANT HOMEFACILITY NUMBER:
198601621
ADMINISTRATOR/
DIRECTOR:		JACLYN VAN ZANTFACILITY TYPE:
735
ADDRESS:455 E. 246TH PLACETELEPHONE:
(310) 518-3372
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 4CENSUS: 3DATE:
07/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:43 PM
MET WITH:Nuria Gabriela QuinteroTIME VISIT/
INSPECTION COMPLETED:
03:44 PM
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On 07/10/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with administrator Nuria Gabriela Quintero. LPA explained the purpose of today’s visit. The facility is licensed to operate for (4) ambulatory adults ages 18 through 59. The clients are all Harbor Regional Center consumers.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: (4) client's rooms, (1) bathroom, a living area, a dining area, a kitchen, an outside seating area, and a garage used for activity room.

LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 105.4 degrees F. A comfortable temperature of 82 degrees F. was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. A fire extinguisher was charged. A review of the Medication Administration Records (MAR) was observed to be maintained in order.

During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and clients, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

(Evaluation Report continues LIC 809-C)
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/10/2024
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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: 246 VAN ZANT HOME
FACILITY NUMBER: 198601621
VISIT DATE: 07/10/2024
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LPA observed First Aid Kit was maintained. A working landline phone was operational. The last fire drill was conducted on 06/18/24. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current liability insurance on file effective 07/15/24 - 07/15/25.

An audit of clients #1-#3 (C1-C3) service files and staff #1-#3 (S1-S6) personnel files revealed to be complete. An audit of the resident's P&I is maintained in order and complete. The facility has the current administrator's certification on file for Nuria G.Quintero #7008726735 Expiration 11/12/2025.

No deficiencies during this inspection visit.

An exit interview was conducted with Nuria Gabriela Quintero and a copy of the report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024
LIC809 (FAS) - (06/04)
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