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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601850
Report Date: 04/24/2023
Date Signed: 05/08/2023 11:09:23 AM

Document Has Been Signed on 05/08/2023 11:09 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:HOME ON CROFTFACILITY NUMBER:
198601850
ADMINISTRATOR:THOMAS, JASMINEFACILITY TYPE:
735
ADDRESS:5909 CROFT AVETELEPHONE:
(323) 348-4182
CITY:LOS ANGELESSTATE: CAZIP CODE:
90056
CAPACITY: 4CENSUS: DATE:
04/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:53 PM
MET WITH:Malika WilliamsTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA was met by Administrator Malika William and the purpose of today’s visit was explained. The facility is licensed to serve 4 ambulatory clients (ages 18-59).

LPA and Malika toured the entire facility inside and out. The home consists of 3 client bedrooms, 2 bathrooms, office, living room, kitchen and dining area. All client rooms were checked. Beds were in good condition, adequate lighting, plenty of dresser and closet space was observed. Walls and floors were clean and in good repair. Bed linens, comforters and bath towels were adequately stocked in each client's room. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly and showers were free of mold/mildew with adequate lighting, and sufficient toiletries were accessible to clients. Water temperature measured at 117.3 F in kitchen, 112.6 F in bathroom #1 and 114.3 F in bathroom #2.

Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Emergency food supplies were located outside in the garage. Smoke detectors/carbon monoxide were working properly, fire extinguishers were fully charged and operational, toxins and knifes were locked and inaccessible to clients. Medications were centrally stored and properly locked. Outside grounds were toured and no bodies of water were observed. Patio furniture with umbrella was accessible. Exits/ Walkways around the home were free of debris and hazards.

There is one (1) deficiency observed: there are bed rails in one bedroom. Exit Interview conducted and a copy of the report was given to Administrator Malika Williams. Please see 809D

Exit interview held. A copy of the report was provided to Malika Williams.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE: DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2023
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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Document Has Been Signed on 05/08/2023 11:09 AM - It Cannot Be Edited


Created By: Felisa Shirley On 04/24/2023 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: HOME ON CROFT
FACILITY NUMBER: 198601850

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80072(a)(8)(B)
80072 Personal Rights (B) A written order from the client's physcian indicating the need for the postural supports shall be maintained in the client's record. The Licensing aagency shall ve authorized to require additional documenation if needed to verifty the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, interview and record review, the licensee did not comply with the section cited above by having supports on the bed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2023
Plan of Correction
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Per Administrator, Malika Williams, she states that she will try to get prescription for doctor ASAP.
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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Felisa Shirley
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2023


LIC809 (FAS) - (06/04)
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