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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601623
Report Date: 06/23/2023
Date Signed: 06/23/2023 03:34:57 PM

Document Has Been Signed on 06/23/2023 03:34 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:PATE ENTERPRISES, INC. ( MENLO )FACILITY NUMBER:
198601623
ADMINISTRATOR:WESLEY PATE, JR.FACILITY TYPE:
735
ADDRESS:14801 GRAMERCY PLACETELEPHONE:
(213) 725-4634
CITY:GARDENASTATE: CAZIP CODE:
90249
CAPACITY: 6CENSUS: DATE:
06/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:37 AM
MET WITH:Renita CampbellTIME COMPLETED:
03:45 PM
NARRATIVE
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On 06/23/23, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced Annual required visit with a primary focus on infection control measures, using the new Care Inspection Tool. LPA was met by Renita Campbell, Staff, and the purpose of today’s visit was explained. Todays census is 4.

The facility is licensed to serve 6 ambulatory adults ages 18 through 59. The facility is a single – story structure located in a residential neighborhood. The facility consists of the following: three (3) client's rooms, two (2) common bathrooms, living area, dining area, kitchen, front and backyards.

LPA and Renita toured the physical plant. All rooms were inspected. Beds and bedding supplies were present, and adequate lighting was provided. The kitchen was inspected and there is perishable and non-perishable food available. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. Fire extinguishers were charged, smoke detectors and carbon monoxide were operable. The water temperature measured at 102.2 F.

LPA and Renita toured the backyard and LPA observed that there was no shaded area present. There were no bodies of water present. LPA observed a locked garage. Staff Renita stated that she does not have access to the locked garage.

LPA reviewed Medication Records and observed them to be maintained in order and accurate.

LPA observed a dead rodent and bugs stuck to a sticky trap in between the refrigerator and counter. LPA tested the stove of which two of the eyes on the stove did not work and the oven did not produce heat. When LPA toured the hall bathroom LPA observed that the toilet was stopped up and did not flush properly. LPA observed that the bed in the back room next to the closet had a mattress with discolored yellow circles on the surface, covered in plastic with a strong urine smell. LPA also observed piles of clothes in the closet.



Con'd on 809-C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2023
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: PATE ENTERPRISES, INC. ( MENLO )
FACILITY NUMBER: 198601623
VISIT DATE: 06/23/2023
NARRATIVE
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Deficiencies are being cited based on LPA observations and interviews conducted in accordance with the California Code of Regulations, Title 22, Divisions 6 chapter 1, see LIC 809D.

An exit interview was conducted, Plans of Corrections were discussed and a copy of this report and appeals rights were and left with Staff, Renita Campbell whose signature on this form confirms receipt of these documents.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023
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Document Has Been Signed on 06/23/2023 03:34 PM - It Cannot Be Edited


Created By: Felisa Shirley On 06/23/2023 at 02:51 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: PATE ENTERPRISES, INC. ( MENLO )
FACILITY NUMBER: 198601623

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
80044(a)(2)
(a) The Licensing agency shall have the inspection authority specified in Health and Safety Code Sections (2) Any duly authorized officer, employee, or agent of the State Department of Social Services may, upon presentation of proper identification, enter and inspect any place providing personal care, supervision, and services at any time, with or without advance notice

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by not allowing access to the garage which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/07/2023
Plan of Correction
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Staff must have keys to garage in the future to allow representatives to inspect facility.
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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Felisa Shirley
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/23/2023 03:34 PM - It Cannot Be Edited


Created By: Felisa Shirley On 06/23/2023 at 03:05 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: PATE ENTERPRISES, INC. ( MENLO )
FACILITY NUMBER: 198601623

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in the stove was not working, hallway toilet was stopped up, a pile of clothes in the closet and a dead rodent and bugs on Sticky Trap in the kitchen, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/07/2023
Plan of Correction
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The Stove and toilet must be prepared, please provide receipt from repairman, the clothes in the closet must be cleaned and put in proper places, the mattress must be cleaned or replaced and a exterminator must come out to service facility and proof of service must be received.
Type B
Section Cited
CCR
85087.2(b)
Outdoor Activity Space
(b) The outdoor activity area shall provide a shaded area, and shall be comfortable, and furnished for outdoor use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in there was no shade or retreat from the sun which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/07/2023
Plan of Correction
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An umbrella or a whole new patio set must be purchased and proovide copy of receipts to LPA.
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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Felisa Shirley
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2023


LIC809 (FAS) - (06/04)
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