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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601785
Report Date: 08/29/2024
Date Signed: 09/05/2024 04:30:14 AM

Document Has Been Signed on 09/05/2024 04:30 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:SPECIALIZED RESIDENTIAL 118TH STREETFACILITY NUMBER:
198601785
ADMINISTRATOR/
DIRECTOR:		SANDRA MORAGAFACILITY TYPE:
735
ADDRESS:5424 W 118TH STTELEPHONE:
(909) 287-3557
CITY:INGLEWOODSTATE: CAZIP CODE:
90304
CAPACITY: 3CENSUS: 3DATE:
08/29/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:23 PM
MET WITH:Cesar MongeTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced Case Management - Annual Continuation visit to complete the annual required visit dated 04/04/2024, with the primary focus on Infection Control measures and using the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA was properly screened for COVID-19 symptoms and LPA temperature was checked. LPA Bunker met Administrator Cesar Monge and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved mitigation plan report and infection control plan. There are currently three (3), Westside Regional Center Adult Residential Care Facility (ARF) consumers in placement. The facility's annual fees are current.

The following 12 Domains will be observed and reviewed: Infection Control, Physical Plant & Environmental Safety, Operational Requirements, Staffing, Personnel Records-Training, Client Rights-Information, Client Records-Incident Reports, Food Service, Health-Related Services, Incidental Medical Services, Disaster Preparedness, and Emergency Intervention. "LPA Bunker will be using this tool and methods that have been developed to improve the efficiency and accuracy of the Department of Social Services' facility inspections."

The facility is a single-story family home located in a residential neighborhood. The facility consists of three (3) client bedrooms, two (2) bathrooms, a living room, an office in the garage, a dining room, two (2) backyard patio areas, a laundry area in the garage, and an attached garage.

See LIC809-C page 2
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SPECIALIZED RESIDENTIAL 118TH STREET
FACILITY NUMBER: 198601785
VISIT DATE: 08/29/2024
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Continued LIC809-C page 2

PPE supplies are readily available to staff, and an additional supply of PPE was observed. Sufficient liquid soap, paper goods, cleaning, and disinfecting supplies were observed. LPA observed staff and residents wearing a face covering and social distancing. House Lead Cesar Monge indicates that staff reviews the PINS and is up to date on the PINs.

Documents are posted as mandated on the kitchen cabinet and garage office area. Bedrooms contain the furniture mandated, and the bathrooms are clean and operational. Personal accommodations were observed for safety, privacy, comfort, and non-skid surface mats. The kitchen was observed for its ability to prepare and serve food. The food service was reviewed for appropriate quantity and proper storage; there was an ample supply of perishable and nonperishable food. The resident’s medications were reviewed for proper storage, documentation, and system implementation. Medications are in a locked cabinet in the kitchen, and records are current. Common areas were observed for the ability to safely serve the needs of the clients, including cleanliness, and clearness of any potential hazards to the residents. The first aid kit is fully stocked with manual, smoke, and carbon monoxide detectors were in compliance, the hot water temperature was measured at 114.3 degrees Fahrenheit within the normal limits (105-120F degrees), the fire extinguishers are fully charged, and adequate linen supply, the facility telephones are working. The client's bedroom windows have no sliding window lock with thumbscrews, all exit doors were in compliance, the yard was free of debris hazards, and trash cans were covered. Staff was given training on dependent adult and elder abuse reporting. The facility conducted a fire drill on July 16, 2024.

There were no deficiencies cited.

Exit interview conducted.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC809 (FAS) - (06/04)
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