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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601965
Report Date: 07/02/2024
Date Signed: 07/02/2024 04:58:53 PM

Document Has Been Signed on 07/02/2024 04:58 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:LURAY HOMEFACILITY NUMBER:
198601965
ADMINISTRATOR/
DIRECTOR:		SHIRENA L MUHAMMADFACILITY TYPE:
735
ADDRESS:930 E. LURAY STREETTELEPHONE:
(562) 612-3752
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY: 3CENSUS: 1DATE:
07/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:55 PM
MET WITH:Maria Varcelo, Direct Support ProfessionalTIME VISIT/
INSPECTION COMPLETED:
04:56 PM
NARRATIVE
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On 07/02/2024 Licensing Program Analyst (LPA) Mario Leon conducted an unannounced annual required visit using the CARE Inspection Tool. LPA was met by Maria Varcelo, Direct Support Professional (DSP) and the purpose of today’s visit was explained.
The facility is licensed to operate for (3) non-ambulatory developmentally disabled or Mentally Ill adults ages 18 through 59. Currently, the home has one (1) non-ambulatory clients. The clients are vended by Harbor Regional Center.The facility is a single-story structure located in a residential neighborhood. It consists of the following: three (3) resident rooms, two (2) bathrooms, living area, dining area, kitchen, and outside shaded area with table and chairs.
LPA and DSP 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. Shower was free of mold/mildew, with adequate lighting and sufficient toiletries accessible to clients was observed. The water temperature properly measured between 105F°-120F° degrees, within title 22 regulations.
Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide/Smoke detectors were observed and operational. Fire extinguishers were fully charged as of 12/11/2023, toxins and knifes were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Last facility disaster drill was conducted on 02/19/2024. LPA reviewed the facility disaster plan and the facility disaster plan was current and in compliance with Title 22, at the time of today's visit.
LPA did not conduct a records review of client records, nor staff records. Due to time constraints, LPA chose to conduct further records review at a later date.
During today's visit, there were two (2) deficiencies cited, please see LIC809D.
An exit interview was held with Maria Varcelo, DSP, and a copy of the facilities' appeals rights and this report was provided.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2024
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 07/02/2024 04:58 PM - It Cannot Be Edited


Created By: Mario Leon On 07/02/2024 at 04:37 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: LURAY HOME
FACILITY NUMBER: 198601965

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2024

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 [(observation), the licensee did not comply with the section cited above in window frame and window cover in Room two (2) needs to be cleaned and sanitized which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2024
Plan of Correction
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The DSP and LPA have agreed that the above-menitoned facility will share photo/video evidence to LPA, at MARIO.LEON@DSS.CA.GOV, of the window in room two (2) that has been cleaned as requested on, or prior to, the due date.
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

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 in The windows in room two (2) and bathroom two (2), screen frame need to be repaired (SKEWED). Window in room three (3) and the laundry room screens need to be replaced which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2024
Plan of Correction
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The DSP and LPA have agreed that the above-menitoned facility will share photo/video evidence to LPA, at MARIO.LEON@DSS.CA.GOV, of The windows in room two (2) and bathroom two (2), screen frame need to be repaired back to square. Window in room three (3) and the laundry room screen(s) need to be replaced as requested on, or prior to, the 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:Ulysses Coronel
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 07/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2024


LIC809 (FAS) - (06/04)
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