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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601622
Report Date: 07/17/2024
Date Signed: 07/17/2024 11:38:49 AM

Document Has Been Signed on 07/17/2024 11:38 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:FARIMAN VAN ZANT HOMEFACILITY NUMBER:
198601622
ADMINISTRATOR/
DIRECTOR:		JACLYN VAN ZANTFACILITY TYPE:
735
ADDRESS:19209 FARIMAN DRIVETELEPHONE:
(310) 763-9269
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY: 4CENSUS: 4DATE:
07/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:16 AM
MET WITH:Carlos ChavarriaTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 07/17/2024, at 9:00am, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced annual required visit using the new CARE Inspection Tool. LPA met with Carlos Chavarria, Direct Care Staff, and explained the purpose of today’s visit. The facility is licensed to operate for four (4) ambulatory developmentally disabled adults of between the ages of 18 through 59. Currently, the home has (4) clients. The clients are Harbor Regional Center clients. None of the clients have Restricted Health Care Conditions and none are utilizing postural supports or protective devices. Facility annual fees are current.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) client rooms, one (1) staff room, two (2) bathrooms, living area, a dining area and kitchen. There is an outside patio area with an umbrella in the middle of the courtyard with ample seating. The backyard is used for outdoor activities. The laundry area is in a locked room located within the recreation room which is the garage. No cars are stored in the garage.

LPA conducted a records review of (4) client records, (5) staff records, (3) clients Personal & Incidental Records and reviewed the facility disaster plan. All client & staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (3) Client Medication Administration Records and did not observe any discrepancies at the time of visit.

LPA and Carlos Chavarria 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.

Report continued on LIC 809-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE: DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2024
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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: FARIMAN VAN ZANT HOME
FACILITY NUMBER: 198601622
VISIT DATE: 07/17/2024
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Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature met Title 22 standards and measured 119.5 F degrees. A comfortable temperature was maintained in the facility. LPA observed the facility to have a first aid kit and manual.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly. There is one (1) fire extinguisher fully charge located near the kitchen wall. Smoke and carbon monoxide detectors were operable. The last fire/earthquake drill was conducted on 07/03/2024.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents. LPA observed that sanitizing stations were in common areas and restrooms. LPA observed that the facility had the required postings, posted throughout the facility. LPA further observed the facility to have a 60-day supply of Personal Protective Equipment (PPE).

LPA advised the administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing (www.cdss.ca.gov) for Provider Informational Notices (PIN) and for any updates relating to COVID-19 guidance and other related issues.

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.

Exit interview held and a copy of the report was provided to Carlos Chavarria, Direct Care Staff.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024
LIC809 (FAS) - (06/04)
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