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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602223
Report Date: 10/19/2021
Date Signed: 10/20/2021 06:51:48 AM

Document Has Been Signed on 10/20/2021 06:51 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME:HEARTWELL HOME 2FACILITY NUMBER:
198602223
ADMINISTRATOR:RODERICK, MARIA SIAFACILITY TYPE:
735
ADDRESS:203 E 219TH STTELEPHONE:
(310) 989-8017
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 4CENSUS: 4DATE:
10/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:19 PM
MET WITH:EBONEY JONESTIME COMPLETED:
03:59 PM
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On 10//19/21, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with the licensee and house manager Tom Roderick and Eboney 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 a single-story structure located in a residential neighborhood. It consists of the following: four (4) client's rooms, two (2) bathrooms, living area, dining area, kitchen, and 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, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 111.4 F. A comfortable temperature of 73 degrees was maintained in the facility.

LPA observed the facility to be sanitary and appropriately furnished at the time of 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 maintained properly. A fire extinguisher was charged, 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 10/03/21.

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2021
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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME: HEARTWELL HOME 2
FACILITY NUMBER: 198602223
VISIT DATE: 10/19/2021
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff and client's temperature logs were reviewed. The facility has a Mitigation Plan Report approved by CCLD on file.

Advisory Notes - Technical Assistance was issued, please see LIC9102-AN.

No deficiencies were cited during this inspection visit.

An exit interview was conducted and a copy of this report was provided to Eboney Jones by email.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021
LIC809 (FAS) - (06/04)
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