198602223-11-4-2023-11-AS-EDAT-CX9K2Q-20231104073131

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602223
Report Date: 11/03/2023
Date Signed: 11/04/2023 07:32:56 AM

Document Has Been Signed on 11/04/2023 07:32 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 2		FACILITY NUMBER:	198602223
ADMINISTRATOR:	RODERICK, MARIA SIA		FACILITY TYPE:	735
ADDRESS:	203 E 219TH ST		TELEPHONE:	(310) 989-8017
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY:	4	CENSUS: 4	DATE:	11/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Ebony Jones		TIME COMPLETED:	12:37 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 11/03/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with the 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 facility is approved for (4) hospice waivers. 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) 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. The water temperature measured 110.6 F. A comfortable temperature of 74 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 accurately. The facility conducted Fire/Safety Drill on 10/23/23. The facility has a working landline. Evaluation Report Continues on LIC 809-C

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
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)

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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 2	FACILITY NUMBER: 198602223
	VISIT DATE: 11/03/2023

NARRATIVE

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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. 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 vaccinations.A review of staff and client files were found to be maintained in order and accurately.

An audit review of client #1-#4 (C1-C4) files and staff #1-#4 (S1-S4) personnel filesAn audit of clients P&I was found to be accurate and complete. . The facility currently has a current surety bond. The facility is current on CCL license annual fees.

Deficiency:
During client's audit of service records, client #4 who was recently admitted on 11/01/23 did not have a physicians report on file. No medical assessment nor a TB test results was performed prior to admission of client.

An exit interview was conducted and a copy of this report was provided to administrator Ebony Jones.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
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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Document Has Been Signed on 11/04/2023 07:32 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HEARTWELL HOME 2	FACILITY NUMBER: 198602223
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80070(b)8)

80070 Client Records (b) Each record must contain information including, but not limited to, the following: (8) Medical assessment, including ambulatory status, as specified in Section 80069. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, the licensee did not comply with the section cited above. No current medical assessement found found for client #4 and no TB results. This violatiion is a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/30/2023
	Plan of Correction
1 2 3 4	The licensee will ensure to obtain a current medical assessment for client #4. Medical assesment will include result for chest x-ray/TB test. Licensee will ensure prior to admitting any new residents that a medical assessment is performed and included in service records. Proof of correciton is due by 11/30/23 sent to LPA ernand.dabuet@dss.ca.gov

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023

LIC809 (FAS) - (06/04)

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