198601843-5-19-2023-11-AS-LMOA-CRYL2A-20230519082201

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601843
Report Date: 05/18/2023
Date Signed: 05/19/2023 08:22:05 AM

Document Has Been Signed on 05/19/2023 08:22 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	219TH FACILITY		FACILITY NUMBER:	198601843
ADMINISTRATOR:	JENNIFER CRIDDLE		FACILITY TYPE:	735
ADDRESS:	1563 W 219TH ST		TELEPHONE:	(310) 533-9870
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90501
CAPACITY: 3		CENSUS: 3	DATE:	05/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	TANISHA MCCALL		TIME COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 5/18/2023, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced annual required visit using the new CARE Inspection Tool. LPA met with Administrator TanIsha McCall and explained the purpose of today’s visit. The facility is licensed to operate for one (1) non-ambulatory and two (2) ambulatory adults ages 18-59. The facility is a single-story structure located in a residential neighborhood. It consists of the following: three (3) client bedrooms, two(2) common bathrooms, living area, dining area, kitchen, family room, garage and outside covered patio. LPA and Administrator 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 was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 114.6 degrees Fahrenheit. A comfortable temperature of 74 degrees was maintained in the facility. LPA observed the facility to be appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, and toxins were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. The facility has (2) fire extinguishers that was charged, smoke detectors, and carbon monoxide were operable. LPA reviewed Medication Administration Records (MAR) and revealed accurate and maintained in order. The facility conducted a Fire/Safety Drill on 4/22/2023. A working telephone (310)-533-9870 remains available. Evaluation Report Continues on LIC 809-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: 219TH FACILITY	FACILITY NUMBER: 198601843
	VISIT DATE: 05/18/2023

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	LPA observed the following deficiencies: Dirty carpets - Client bedrooms #1 & # 2 Unfinished patch up paints in the dining room, hallway and family room Broken window screen Deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Exit interview conducted. Appeal rights and a copy of this report was provided to Administrator Tanisha McCall.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/19/2023 08:22 AM - It Cannot Be Edited

Created By: Lourdes Montoya On 05/18/2023 at 03:39 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: 219TH FACILITY	FACILITY NUMBER: 198601843
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/18/2023

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
1 2 3 4	Based on observation and records review, the licensee did not comply with the section cited above. At 10:16 am, LPA Montoya observed the carpet in client bedroom #1 is dirty. At 10:17 am, LPA Montoya observed the carpet in client bedroom #2 is dirty. LPA also observed unfinished patched up paints on the wall in the dining area, hallway and family room. A broken window screen was also observed. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/09/2023
	Plan of Correction
1 2 3 4	Administrator shall have the carpets cleaned, paint the walls and replace the window screen. Administrator shall send POC to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Lourdes Montoya

LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023

LIC809 (FAS) - (06/04)

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