198602012-10-23-2024-11-AS-LVIS-DABQ2P-20241023114727

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602012
Report Date: 10/23/2024
Date Signed: 10/23/2024 11:47:34 AM

Document Has Been Signed on 10/23/2024 11:47 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	C&H #7 RESIDENTIAL CARE FOR ELDERLY		FACILITY NUMBER:	198602012
ADMINISTRATOR:	ASHLEY ADLEAN		FACILITY TYPE:	740
ADDRESS:	4702 EAST SAN VINCENTE STREET		TELEPHONE:	(562) 630-8123
CITY:	COMPTON	STATE: CA	ZIP CODE:	90221
CAPACITY:	4	CENSUS: 3	DATE:	10/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	DSP Yazmin Fraire		TIME COMPLETED:	12:15 PM

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On 10/23/24, Licensing Program Analyst (LPA) Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with DSP Yazmin Fraire as the purpose of the visit was explained. The facility is licensed to serve 4 ambulatory only elderly adults 60 and over, current census 3. Clients are linked to the South-Central Los Angeles Regional Center. LPA provide info and pin for upcoming annual fees.

The facility is a single-story structure located in a residential neighborhood and consists of the following: (3) bedrooms, (1) full bathrooms, and 1/2 bath, linen closet, kitchen with a staff work area, shaded back yard, and a detached 2 garage that houses a washer and dryer and emergency water supply. There are no bodies of water nor firearms on the property, walkways are free of debris/hazards.

LPA conducted a records review of 2 staff records, 3 client records, and 3 medication administration record. No discrepancies observed. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire was conducted on 09/03/24, fire extinguisher fully charged, carbon monoxide and smoke detectors observed and are operational with the exception of hallway smoke detector cited on 809D. Landline and internet service was observed. Liability insurance active (92561582014)with expiration date of 06/22/2025, surety bond (62622408) with western surety company is active.

Client bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, shower was free of mold/mildew, and there are sufficient toiletries accessible to clients. The water temperature properly measured between 105-120 F..Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Toxins and knifes were observed to be stored and inaccessible to clients. Exits/ Walkways around the facility were free of debris and hazards.

Exit interview conducted with DSP Yazmin Fraire, and a copy of the report was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024

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 10/23/2024 11:47 AM - It Cannot Be Edited

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: C&H #7 RESIDENTIAL CARE FOR ELDERLY	FACILITY NUMBER: 198602012
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87217(g)(1)

87217 Safeguards for Resident Cash, Personal Property, and Valuables Each licensee shall maintain adequate safeguards and accurate records of cash resources and valuables entrusted to his care, including, but not limited to the following: Records of residents' cash resources maintained as a drawing account shall include a ledger accounting (columns for income, disbursements and balance) for each resident, and supporting receipts filed in chronological order. Each accounting shall be kept current.
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the licensee did not have P&I records available for review at the time of visit which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/06/2024
	Plan of Correction
1 2 3 4	Licensee to send LPA a copy of all current P&I ledgers that shows all current balance by POC due date. Licensee shall ensure that P&I ledgers are current and at the facility at all times.

Type B

Section Cited

CCR

87203

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) the licensee did not comply with the section cited above as smoke detector in the hallway between the dinning room and kitchen is not operational which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/06/2024
	Plan of Correction
1 2 3 4	Licensee to ensure smoke detector is operational at all times, Licensee to provide prook of repair to LPA by POC 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	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024

LIC809 (FAS) - (06/04)

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