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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602222
Report Date: 11/03/2023
Date Signed: 11/04/2023 07:27:10 AM

Document Has Been Signed on 11/04/2023 07:27 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: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:
11/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:51 PM
MET WITH:Ebony Jones TIME COMPLETED:
03:59 PM
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On 11/03/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with house manager Ebony Jones. 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 water temperature of 105.0 degrees F. A comfortable temperature of 74 degrees F. 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 09/08/23. 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: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 11/03/2023
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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 the facility has a 30-day supply of Personal Protective Equipment (PPE). Posters mandated for inspection control were posted.

An audit of clients #1-#4 service records and staff #1-#4 personnel records revealed to be completed. Interviews conducted with (1) client and (2) staff. A review of client's P&I found to be maintained in order and accurate. The has a current surety bond coverage. The facility is current on CCL annual dues.

No deficiencies cited during this inspection visit.

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

DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023
LIC809 (FAS) - (06/04)
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