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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601934
Report Date: 11/22/2024
Date Signed: 12/03/2024 01:26:08 PM

Document Has Been Signed on 12/03/2024 01:26 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:CBG HOME INC.FACILITY NUMBER:
198601934
ADMINISTRATOR/
DIRECTOR:		NEEKOLE GLASPIEFACILITY TYPE:
735
ADDRESS:13413 S. VAN NESS AVENUETELEPHONE:
(310) 327-2531
CITY:GARDENASTATE: CAZIP CODE:
90249
CAPACITY: 6CENSUS: 4DATE:
11/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:39 AM
MET WITH:Kimberly Cooper TIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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On 12/03/24 , Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with House Manager Kimberly Cooper. LPA explained the purpose of today’s visit. The facility is licensed to operate for (6) non-ambulatory of which may be (1) bedridden adults 18 through 59. The residents are all Westside Regional Center consumers.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: (3) client rooms, (1) staff room, (2) bathrooms, a living area, a dining area, a kitchen, an outside seating area, and a garage used for storage.

LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bed linens, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 105.7 degrees F. A comfortable temperature of 72 F. degrees was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. A fire extinguisher was charged. A review of the Medication Records Administration (MAR) was observed to be maintained in place.

LPA observed First Aid Kit was maintained. A working landline phone was operational. The last fire drill was conducted on 03/01/24. The facility had operational smoke and carbon monoxide in bedrooms and common areas.
(Evaluation Report continues LIC 809-C)
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2024
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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Document Has Been Signed on 12/03/2024 01:26 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 12/03/2024 at 12:33 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: CBG HOME INC.
FACILITY NUMBER: 198601934

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observatoin, the licensee did not comply with the section cited above. LPA identified client room #2 smoke detector non-operable and ceiling and fan free from dust. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/17/2024
Plan of Correction
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Licensee will ensure to replace/repair smoke detector and conduct deep cleaning in client #2 room to ensure that room is dust-free. Proof of correction must be sent to LPA Dabuet with photographs at ernand.dabuet@dss.ca.gov by due date.
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA identified toilet was not flushing in main bathroom #1. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/17/2024
Plan of Correction
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Licensee will ensure to replace/repair toilet. Proof of correction must be sent to LPA Dabuet with photographs at ernand.dabuet@dss.ca.gov by due date.
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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/03/2024 01:26 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 12/03/2024 at 12:34 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: CBG HOME INC.
FACILITY NUMBER: 198601934

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(12)(B)1
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) For employees that are required to be fingerprinted pursuant to Section 80019: (B) Documentation of either a criminal record clearance or exemption as required by Section 80019(e). 1. For Certified Administrators, a copy of their current and valid Administrator Certification meets this requirement.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. LPA identified the licensee did not have a current or valid administrator's cerfificate on file with CCL. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/17/2024
Plan of Correction
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Licensee will ensure to send proof of Administrator's Certificate renewal for NEEKOLE GLASPIE. Proof of correction must be sent to LPA Dabuet at ernand.dabuet@dss.ca.gov by due date.
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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2024


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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: CBG HOME INC.
FACILITY NUMBER: 198601934
VISIT DATE: 11/22/2024
NARRATIVE
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

An audit of clients #1-#4 (C1-C4) service files and staff #1-#4 (S1-S4) personnel files revealed to be complete. The facility is current on CCL annual license fees.

Deficiencies:
  • The facility did not have a copy of a current and valid Administrator Certificate.
  • Main bathroom #1 had non-working toilet that did not flush properly.
  • Client room #2 did not have working smoke detector.
  • Client room #2 ceiling and fan surfaces were not dust-free.


According to the California Code of Regulations (Title 22, Division 6, Chapter 1), the following deficiencies has been observed and citation issued (ref. LIC 9099-D).

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *

An exit interview was conducted with Kimberly Cooper a copy of the report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC809 (FAS) - (06/04)
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