198601844-6-21-2023-11-AS-JCAN-CSZT3Z-20230621142311

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601844
Report Date: 06/21/2023
Date Signed: 06/21/2023 02:51:16 PM

Document Has Been Signed on 06/21/2023 02:51 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:	PEPPERWOOD AVENUE FACILITY		FACILITY NUMBER:	198601844
ADMINISTRATOR:	DAVENPORT, RENEE		FACILITY TYPE:	735
ADDRESS:	4735 PEPPERWOOD AVE		TELEPHONE:	(562) 982-4237
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90808
CAPACITY: 3		CENSUS: 3	DATE:	06/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:18 AM
MET WITH:	ADMINISTRATOR RENEE DAVENPORT		TIME COMPLETED:	03:00 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 06/21/2023 at 11:15 AM, Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced annual inspection visit at the Pepperwood Avenue Facility. LPA Calderon was allowed entry into the facility by Administrator Renee Davenport. Administrator Renee Davenport was asked questions regarding the full care tools control package (13) sections. Administrator Renee Davenport took LPA Calderon temperature prior to entrance into the facility. The facility is licensed for three (3) adult clients with developmental disabilities. Currently, there are three (3) residents residing in the facility with developmental disabilities. LPA Calderon explained to Administrator Renee Davenport, the purpose of the one-year (1) Annual Inspection visit, and escorted LPA Calderon on a tour of the entire inside and outside facility grounds. As part of the inspection, LPA Calderon reviewed: three (3) resident service records, three (3) resident medication records, two (2) staff records. LPA Calderon interviewed three (3) residents and two (2) staff members for visit. LPA Calderon inspected the inside facility and outside grounds to include all common areas. The facilities’ last fire drill was conducted on 06/01/2023. The one-story residential home consists of three (3) resident bedrooms, two (2) resident bathrooms, living room, dining room, family room, kitchen, office area, attached garage with washer and dryer/ storage area, backyard with table and chairs. No weapons are stored in the premises. Kitchen was inspected and observed to be clean and operational. A two-day (2) supply perishable and seven-day (7) supply of non-perishable foods are present in the facility. Emergency Water seven-day (7) supply is found in the garage.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023

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: PEPPERWOOD AVENUE FACILITY	FACILITY NUMBER: 198601844
	VISIT DATE: 06/21/2023

NARRATIVE

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During the visit, LPA Calderon observed the facility infection control practices. LPA Calderon observed screening protocols for visitors, staff, and residents, sanitizing stations (Located in common areas and restrooms). LPA Calderon observed staff and residents were wearing face coverings, an isolation room and required postings throughout the facility. LPA Calderon observed the facility has a thirty-day (30) supply of Personal Protective Equipment (PPE).

LPA Calderon advised the Administrator Renee Davenport to continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA Calderon did not observe any deficiencies therefore NO citations were issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Administrator Renee Davenport.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023

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: PEPPERWOOD AVENUE FACILITY	FACILITY NUMBER: 198601844
	VISIT DATE: 06/21/2023

NARRATIVE

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LPA Calderon observed that all facility rooms are clean and in good repair. A comfortable temperature was observed, and the facility has central air and heating. LPA Calderon observed the following during inspection of resident’s rooms: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, LPA Calderon observed fully stocked closet with bedding, towels, and toiletries supplies. Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. LPA Calderon observed bathrooms were found to be within Title 22 regulation. Bathroom #1 hot water temperature properly measured at 111 degrees Fahrenheit. Bathroom #2 hot water temperature properly measured at 110 degrees Fahrenheit. Kitchen hot water temperature properly measured at 115 degrees Fahrenheit. Facility (2) carbon Monoxide and (8) Smoke Detectors hard wired and were tested and are working properly. The facility two (2) Fire Extinguishers were checked and found to be fully charged and accessible. All exit doors in the facility have alarm systems. All toxins and knifes are locked/secured and inaccessible to residents. Medications are centrally stored and in a locked storage cabinet. Facility first aid kit (1) is fully stocked with manual was checked and in order. Outside grounds were toured and no bodies of water were observed. All Exits/ Walkways around the home were free of debris and hazards. Outside patio accessible to residents. LPA Calderon reviewed three (3) resident files and found to be complete. LPA Calderon reviewed three (3) resident medications and they were all found to be administered according to doctor's orders. Two (2) staff files were checked and have the required documents. LPA Calderon noted the Administrator Renee Davenport Certification # 6033364735 expiration date of 08/09/2023 was valid at time of visit. The facility does handle resident's money/cash resources and a Surety bond is needed. Western Surety Company #71499039 for $3000.00 dollars. Commercial General Liability Policy #ACP3039558980 policy period from 01/01/2023 to 01/01/2024 and a Commercial Professional Liability Insurance Policy #ACP3039558980 policy period from 01/01/2023 to 01/01/2024 underwritten by Nationwide Mutual Insurance Company, coverage 1,000,000/3,000,000 is valid at time of inspection. LPA Calderon spoke to Administrator Renee Davenport who will email full copy of insurance contact which shows all coverages to LPA Calderon on 07/10/2023. All the required documents are posted in the facility in a clearly visible area to all staff, clients, and guests. LPA Calderon reviewed LIC500 and noted all staff associated to facility per LIS. LPA Calderon reviewed the resident roster, LPA Calderon confirmed residents’ interview are on resident roster.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023

LIC809 (FAS) - (06/04)

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