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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602222
Report Date: 11/26/2022
Date Signed: 11/26/2022 12:51:12 PM

Document Has Been Signed on 11/26/2022 12:51 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:HEARTWELL HOME 1FACILITY NUMBER:
198602222
ADMINISTRATOR:RODERICK, MARIA SIAFACILITY TYPE:
735
ADDRESS:22908 ANCHOR AVETELEPHONE:
(310) 989-8017
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 4CENSUS: 4DATE:
11/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH:Terista GarongTIME COMPLETED:
12:47 PM
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On 11/26/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA met with the Direct Support Provider Terista Garong. LPA explained the purpose of today’s visit. The facility is licensed to operate for four (4) ambulatory adults ages 18 through 59. The clients are Harbor Regional Center consumers. The facility is approved for four (4) Hospice clients.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) clients' rooms, two (2) bathrooms, a living area, a dining area, a kitchen, and an outside patio area.

LPA toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of the visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. A comfortable temperature of 71 degrees was maintained in the facility.

LPA observed the facility to be sanitary and appropriately furnished during the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained adequately. A fire extinguisher was charged, and smoke detectors and carbon monoxide were operable. A review of Medication Records Administration (MAR) and Fire Drills were observed to be maintained in order and accurate. The facility conducted Fire/Safety Drill on 11/04/22. The facility has a working landline telephone. The staff had all current CPR/First Aid Training on file. The facility has current liability insurance.

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 11/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/26/2022
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: HEARTWELL HOME 1
FACILITY NUMBER: 198602222
VISIT DATE: 11/26/2022
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INFECTION CONTROL:
During the visit, LPA observed the facility's infection control practices. LPA observed staff followed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). Posters mandated for inspection control were posted. The vaccinations of staff and residents were reviewed. The facility has a Mitigation Plan Report approved by CCLD on file along with Infection Control and Monkey Pox 2022 Plans.

DEFICIENCY:
The water temperature for bathroom #1 tested at 132.9 F and bathroom #2 at 131.9 F.

Deficiency cited during this visit (see LIC 809-D).

An exit interview was conducted and a copy of this report and appeal rights were provided to Terista Garong.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/26/2022 12:51 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 11/26/2022 at 12:12 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: HEARTWELL HOME 1
FACILITY NUMBER: 198602222

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(1)(2)
80088 Furniture, Fixtures, Equipment, and Supplies (1) 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). (2) Taps delivering water at 125 degrees F (51.6 degrees C) or above shall be prominently identified by warning signs.


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 and tested hot water temperature for bathrooms 131.9 and 132.9. This violation poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2022
Plan of Correction
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The licensee will ensure that hot water temperature shall be maintained to regulate at 105.0 F and ot more than 120.F by Title 22 Regulation standards. Licensee will submit proof of correction by send a fax with corrected temperature to 323-918-1781 by POC due date: 11/28/22.
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: 11/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2022


LIC809 (FAS) - (06/04)
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