198601899-10-6-2023-11-AS-PBUR-CWCLGP-20231006084504

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601899
Report Date: 10/04/2023
Date Signed: 10/06/2023 08:45:26 AM

Document Has Been Signed on 10/06/2023 08:45 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	JEFFERSON MANOR		FACILITY NUMBER:	198601899
ADMINISTRATOR:	CZARINA DOROTAN		FACILITY TYPE:	740
ADDRESS:	1662 W. JEFFERSON BLVD.		TELEPHONE:	(213) 880-5505
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90018
CAPACITY:	6	CENSUS: 4	DATE:	10/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	07:59 AM
MET WITH:	Chilly Navarro and Mark Leonor		TIME COMPLETED:	01:15 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	Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced required 1- year visit with the primary focus on Infection Control measures and using the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA was properly screened for COVID-19 symptoms and temperature was checked. LPA Bunker met Assistant Administrator Chilly Navarro and staff Mark Leonor and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved mitigation plan report. There are currently four (4) South Central Los Angeles Regional Center residents in placement. The facility's annual fees are current. 12 Domains in the Infection Control Practices will be observed and reviewed. "I will be using this tool and methods that have been developed to improve the efficiency and accuracy of the Department of Social Services' facility inspections." The facility is a single-story family home located in a residential neighborhood with, a living room, dining area, kitchen, 4 bedrooms, 2 bathrooms, an outside laundry room, and an indoor/outdoor activity area. A shaded area with outdoor patio furniture, table, and chairs. Bedrooms #1-4 are designated as the resident's bedrooms. During the tour, LPA Bunker observed sanitizer, visitor log, and thermometer at the facility entrance. Logs of daily COVID-19 screening and temperature checks of clients and staff were available and updated. PPE supplies are readily available to staff, and an additional supply of PPE was observed. sufficient liquid soap, paper goods, cleaning, and disinfecting supplies were observed. LPA observed staff and residents wearing a face covering and social distancing. See continued LIC809-C page 2

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: JEFFERSON MANOR	FACILITY NUMBER: 198601899
	VISIT DATE: 10/04/2023

NARRATIVE

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Continued LIC809-C page 2

Documents have been diligently posted as mandated on the wall in the kitchen and breakfast area. The following Title 22 regulated areas were audited and found to be in compliance: Bedrooms contain the required furniture, and bathrooms are clean and operational. Personal accommodations were observed for safety, privacy, and comfort, including the provision of non-skid surface mats. The kitchen was observed for its ability to prepare and serve food. The food service was reviewed for appropriate quantity and proper storage; there was an ample supply of perishable and nonperishable food. The resident’s medications were reviewed for proper storage, documentation, and system implementation. Medications are securely locked, and records are current and up to date. Common areas observed for the ability to safely serve the needs of the residents, including cleanliness, and clear of any potential hazards to the residents. The first aid kit is fully stocked with manual, smoke, and carbon monoxide detectors were in compliance, the hot water temperature was measured within normal limits at 120 degrees Fahrenheit (within the range of 105-120 degrees Fahrenheit). The fire extinguisher is fully charged, adequate linen supply, and the facility's telephones are tested and found to be in working order, The client's bedroom windows have no sliding window lock with thumbscrews, all exit doors were found to be in compliance, the yard was free of debris hazards, and trash cans were covered. Staff members have undergone training on reporting dependent adult and elder abuse. The facility conducted a fire drill on September 18, 2023.

There were no deficiencies cited.

Exit interview conducted.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

LIC809 (FAS) - (06/04)

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