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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601711
Report Date: 07/24/2024
Date Signed: 07/24/2024 12:49:47 PM

Document Has Been Signed on 07/24/2024 12:49 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:HAMUD RESIDENTIAL HOME, THEFACILITY NUMBER:
198601711
ADMINISTRATOR/
DIRECTOR:		NORMA HAMUDFACILITY TYPE:
735
ADDRESS:2517 EAST 219TH PLACETELEPHONE:
(424) 264-5186
CITY:LONG BEACHSTATE: CAZIP CODE:
90810
CAPACITY: 6CENSUS: 4DATE:
07/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:09 AM
MET WITH:Administrator Norma HamudTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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On 07/24/24, Licensing Program Analyst (LPA) Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Administrator Norma Hamud, as the purpose of the visit was explained. The facility is licensed to serve (6) clients ages 18-59, facility is approved for (2) non-ambulatory. Current facility census is (4), clients are linked to the Harbor Regional Center. Administrator was provided with upcoming fees info.

The facility is a single-story structure located in a residential neighborhood and consists of the following: (4) client bedrooms, (2) client bathrooms, living room, dining room, kitchen, staff room, office area, attached garage with washer and dryer/ storage area, and emergency water supply, backyard with table and chairs. No weapons are stored in the premises. Kitchen was inspected and observed to be clean and operational. A (2) day supply perishable and a (7)day supply of non-perishable foods are present in the facility. Client bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, shower was free of mold/mildew, and there are sufficient toiletries accessible to clients. The water temperature properly measured between 105-120 F., toxins and knifes were stored and inaccessible to clients, no weapons nor bodies of water on the premises, exits and walkways are free of debris/hazards.

LPA conducted a records review of 3 staff records, 4 client records, and 4 medication administration records, no discrepancies observed. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The facility (2) Fire Extinguishers were checked and found to be fully charged and accessible, carbon monoxide and smoke detectors are interconnected and operational.

Citations documented on 809D.

Exit interview conducted with Administrator Norma Hamud, appeal rights explained. and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2024
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 3
Document Has Been Signed on 07/24/2024 12:49 PM - It Cannot Be Edited


Created By: Lizeth Villegas On 07/24/2024 at 12:16 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: HAMUD RESIDENTIAL HOME, THE
FACILITY NUMBER: 198601711

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(c)(1-5)
80069 client medical assessment
(c) The medical assessment shall include the following:

(1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

(2) Identification of the client's special problems and needs.

(3) Identification of any prescribed medications being taken by the client.

(4) A determination of the client's ambulatory status, as defined by Section 80001(n)(2).

(5) Identification of physical restrictions, including any medically necessary diet restrictions, to determine the client's capacity to participate in the licensee's program.
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in there is no documentation of client #1 and Client #2 physician report which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/02/2024
Plan of Correction
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Administrator to provide proof of completed physicians report by POC due date. Per Administrator an appointment has been made for 07/31/24.
Type B
Section Cited
HSC
1565(c)
1565 Health and safety code
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as there is no documentation of drills being conducted which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2024
Plan of Correction
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Administrator will conducted a drill and will submit proof to LPA by POC due date.
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:Janae Hammond
LICENSING EVALUATOR NAME:Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/24/2024 12:49 PM - It Cannot Be Edited


Created By: Lizeth Villegas On 07/24/2024 at 12:31 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: HAMUD RESIDENTIAL HOME, THE
FACILITY NUMBER: 198601711

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80026(a)(b)(6)


80022 Plan of Operation

80026 Plan of operation

Each licensee shall have and maintain on file a current, written, definitive plan of operation.

The plan and related materials shall contain the following:

Plan for inservice education of staff if required by regulations governing the specific facility category.
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as staff #1 and Staff #2 do not have DSP 1 training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/07/2024
Plan of Correction
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Administrator to submit proof ofenrollment and completion of DSP 1 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:Janae Hammond
LICENSING EVALUATOR NAME:Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024


LIC809 (FAS) - (06/04)
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