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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601839
Report Date: 10/22/2021
Date Signed: 10/22/2021 02:01:50 PM

Document Has Been Signed on 10/22/2021 02:01 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:HEARTS QUALITY CARE INC.FACILITY NUMBER:
198601839
ADMINISTRATOR:ERRICK JOHNSONFACILITY TYPE:
735
ADDRESS:4904 2ND AVETELEPHONE:
(323) 501-9261
CITY:LOS ANGELESSTATE: CAZIP CODE:
90043
CAPACITY: 4CENSUS: 3DATE:
10/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:26 PM
MET WITH:Ebony Brown, Administrator TIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Jennifer Jones conducted an unannounced 1 year Annual visit to the facility. The facility is licensed for four (4) ambulatory client, prefers to serve developmentally disabled adults ages 18 thru 59 years. LPA was greeted by Administrator, Ebony Brown and LPA explained the reason for the visit.

During today’s visit, LPA observed the following: The facility is a single-story home located in a residential area which includes two (2) client bedrooms, two and half (2 1/2) bathrooms, living room, dining room, kitchen, Office, and TV room, laundry area, backyard patio with shaded area, and an attached garage. Bedrooms #1 and #2 are designated for clients and contain furniture and lighting fixtures as mandated, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Walls and floors were clean and in good repair.

Emergency food supplies is stored in the garage. Outdoor and indoor passageways are kept free of obstruction. There are no pools, or bodies of water on the premises. LPA observed a jacuzzi in the facility, however jacuzzi is empty, and inaccessible to clients. There are no firearms on the premises and other dangerous weapons such as knifes are locked. Disinfectants, cleaning solutions, poisons are inaccessible to clients in locked cabinet located under the kitchen sink. Fully charged fire extinguisher is located in the kitchen. LPA observed required perishable and nonperishable food items. A comfortable temperature for clients is maintained. Lamps or lights in all rooms were observed. Toilets, hand washing and showers/bathtubs are in safe, sanitary, operating conditions. LPA observed hygiene supplies next to the medication cabinet in the den. Smoke detector and carbon monoxide detector are operational.

LPA reviewed staff and resident records. LPA observed medications locked and inaccessible to the clients in care.
SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jennifer Jones
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2021
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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: HEARTS QUALITY CARE INC.
FACILITY NUMBER: 198601839
VISIT DATE: 10/22/2021
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During the visit, LPA observed the facility infection control practices. LPA observed a sign in sheet with thermometer for staff and visitors LPA observed staff wearing mask. The administrator has another room for isolation purposes. LPA observed a posting at the front door and additional posting throughout the facility. LPA observed PPE supplies in the garage inaccessible to the client in care. The administrator advised LPA that the facility does not get visitors but if a visitor shows up then they have the option to meet with a client inside or outside.

No deficiencies issued under California Code of Regulations of Regulations Title 22.

Exit interview conducted and a copy of this report was given at the time of visit

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jennifer Jones
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021
LIC809 (FAS) - (06/04)
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