198601930-5-26-2023-11-AS-PBUR-CS7NUD-20230526104611

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601930
Report Date: 05/16/2023
Date Signed: 05/26/2023 10:46:35 AM

Document Has Been Signed on 05/26/2023 10:46 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:	FLAGSHIP @ LA SALLE		FACILITY NUMBER:	198601930
ADMINISTRATOR:	CAFFEY, SHERITA		FACILITY TYPE:	735
ADDRESS:	9129 LA SALLE AVE		TELEPHONE:	(323) 920-6523
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90047
CAPACITY: 3		CENSUS: 2	DATE:	05/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Sherita Rembert		TIME COMPLETED:	03:30 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 LPA temperature was checked. LPA Bunker met with Administrator Sherita Rembert and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved mitigation plan report. There are currently two (2) South Central Los Angeles Regional Center (SCLARC) Adult Residential Care Facility (ARF) consumers in placement. The following 11 Domain will be observed and reviewed: Infection Control, Physical Plant & Environmental, Operational Requirements, Staffing, Personnel Records-Training, Client Rights-Information, Client Rights-Incident Reports, Food Service, Health-Related Services, Incidental Medical Services, and Disaster Preparedness "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. Staff Pamella Santos and LPA Bunker toured the facility which consisted of the following: Living room, kitchen, dining room, office area, 3 bedrooms, 1 ½ bathrooms, laundry room, detached garage, shaded area, and indoor/outdoor activity area. The front and back yard landscape is in good condition at the time of the visit. See continued LIC809-C on page 2

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

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: FLAGSHIP @ LA SALLE	FACILITY NUMBER: 198601930
	VISIT DATE: 05/16/2023

NARRATIVE

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Continued LIC809-C page 2

Documents are posted as mandated. Bedrooms contain the furniture mandated, and bathrooms are clean and operational. Personal accommodations were observed for safety, privacy, comfort, and 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 locked, and records are current. 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 was in compliance, the fire extinguisher is fully charged, adequate linen supply, and the facility telephones are working. The client's bedroom windows have no sliding window lock with thumbscrews, all exit doors were in compliance, the yard was free of debris hazards, and trash cans were covered. Staff was given training on dependent adult and elder abuse reporting. The facility conducted a fire drill on December 05, 2022

According to the California Code of Regulations, Title 2, Division 6, Chapter 1. LPA Bunker observed the following deficiencies, the facility is being cited on the attached LIC809-D. Appeal Rights issued and discussed.

Exit interview conducted.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/26/2023 10:46 AM - It Cannot Be Edited

Created By: Pamela Bunker On 05/16/2023 at 02:58 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: FLAGSHIP @ LA SALLE	FACILITY NUMBER: 198601930
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited


	Deficient Practice Statement
1 2 3 4	80087 (a) Buildings and Grounds: 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. The facility carpet in the living room, hallway, and bedrooms, high traffic area has wear and tear, stains with dark brown and black spots.
	POC Due Date: 06/19/2023
	Plan of Correction
1 2 3 4	The licensee needs to replace the carpet in the facility's living room, hallway, and bedrooms. This violation poses a potential health and safety risk to clients in care.

Section Cited


	Deficient Practice Statement
1 2 3 4	80088 (e) (1) Furniture, Fixtures, Equipment, and Supplies: Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).
	POC Due Date: 05/17/2023
	Plan of Correction
1 2 3 4	The hot water temperature was measured at 145.8 degrees Fahrenheit, This violation poses an immediate health and safety risk to clients in care.

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:

Pamela Bunker

LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

LIC809 (FAS) - (06/04)

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