198601850-5-4-2024-11-AS-AINZ-D4XQGW-20240504121013

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601850
Report Date: 05/04/2024
Date Signed: 05/04/2024 12:10:19 PM

Document Has Been Signed on 05/04/2024 12:10 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	HOME ON CROFT		FACILITY NUMBER:	198601850
ADMINISTRATOR/ DIRECTOR:	WILLIAMS, MALIKA		FACILITY TYPE:	735
ADDRESS:	5909 CROFT AVE		TELEPHONE:	(323) 348-4182
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90056
CAPACITY: 4		CENSUS: 3	DATE:	05/04/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Malika Williams-Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:04 PM

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On 5/4/24 Licensing Program Analysts (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPAs met with Malika Williams/Administrator and the purpose of today’s visit was explained. The facility is licensed to operate for (4) non-ambulatory developmentally disabled or Mentally Ill adults ages 18 through 59 ambulatories only. Currently, the home has (3) clients. The clients are from: Westside Regional Center. (1) Restricted Health Care Conditions, and (1) utilizes postural support or protective devices. Staff to client ratio is (1:2).

The facility is located on a residential neighborhood, it consists of 3 client bedrooms, 2 bathrooms, office, living room, kitchen, and dining area.

LPA Iniguez and administrator toured the inside and outside of the facility. All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting was observed, plenty of dresser and closet space was observed. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly. The shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature properly measured between 105F°-120F° degrees (Kitchen 110.8F°, Bathroom #1 107.8°F).

Evaluation Report continues LIC 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2024

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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: HOME ON CROFT	FACILITY NUMBER: 198601850
	VISIT DATE: 05/04/2024

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LPA Iniguez observed the facility clean, sanitary, and appropriately furnished at the time of the visit. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. Carbon monoxide/Smoke detectors were observed and operational. Fire extinguishers were fully charged, toxins and knives were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last facility disaster drill was:4/29/24. LPA reviewed the facility disaster plan. The facility disaster plan was current and in compliance with Title 22 at the time of visit.

A total of (3) clients records and (3) staff records and (3) Medication Administration Records (MARS) LPAs found no discrepancies at the time of the visit. Facility licensee fees are current.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See details below:

-Facility staff not associated at facility: S#1 and S#2 (see LIC 859 for details)

-Civil Penalty Assessed for $1000.

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Malika Williams /Administrator.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/04/2024 12:10 PM - It Cannot Be Edited

Created By: Alfonso Iniguez On 05/04/2024 at 11:57 AM

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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: HOME ON CROFT	FACILITY NUMBER: 198601850
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80019(e)(3)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in 2 facility staff not associated which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/06/2024
	Plan of Correction
1 2 3 4	Licensee will ensure all facility staff is associated at the facility. As plan of correction, licensee will associate the 2 staff that are not and send proof of association to LPA via email before 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:

Eva M Alvarez

LICENSING EVALUATOR NAME:

Alfonso Iniguez

LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2024

LIC809 (FAS) - (06/04)

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