198602236-9-8-2023-11-AS-PBUR-CVH2A8-20230908171308

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602236
Report Date: 09/08/2023
Date Signed: 09/08/2023 05:13:13 PM

Document Has Been Signed on 09/08/2023 05:13 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:	LADERA HOMES I		FACILITY NUMBER:	198602236
ADMINISTRATOR:	FAULKNER, RENEE		FACILITY TYPE:	740
ADDRESS:	6118 SOUTH LA BREA AVENUE		TELEPHONE:	(323) 447-2231
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90056
CAPACITY:	5	CENSUS: 4	DATE:	09/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Renee Faulkner		TIME COMPLETED:	02:45 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	Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced Annual Required 1-Year visit with the primary focus on Infection Control measures and using the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA Bunker was properly screened for COVID-19 symptoms and temperature was checked. LPA Bunker met with Licensee Renee Faulkner and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved Mitigation Plan Report and Infection Control Plan Report. There are currently four (4), residents in placement. The facility's annual fees are current. The following Domains will be observed and reviewed: Infection Control, Operational Requirements, Physical Plant and Environmental Safety, Staffing, Personnel Records-Staff Training, Residents Records-Incident Reports, Resident Rights-Information, Planned Activities, Food Service, Incidental Medical and Dental, Disaster Preparedness, and Resident with Special Health Needs,. "LPA Bunker will be using this tool and methods that have been developed to improve the efficiency and accuracy of the Department of Social Services facility inspections. The facility is a single-family home located in a residential neighborhood. Licensee/Administrator Renee Faulkner and LPA Bunker toured the facility which consisted of the following: Living room, dining/family room, kitchen, 4 bedrooms, 1.5 bathrooms, office area, laundry area, shaded area, indoor/outdoor activity areas, and attached garage. The front and back yard landscape is in good condition at the time of the visit. See continued LIC809-C on page 2

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

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: LADERA HOMES I	FACILITY NUMBER: 198602236
	VISIT DATE: 09/08/2023

NARRATIVE

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Continued LIC809-C page #2

During the tour, LPA observed the facility’s infection control practices. LPA observed sanitizer, visitor log, and thermometer at the facility entrance. Logs of daily COVID-19 screening and temperature checks of residents and staff were available and updated. PPE supplies are readily available to staff, and an additional supply of PPE was observed. Sufficient liquid soap, paper goods, cleaning, and disinfecting supplies were observed. LPA observed staff and residents wearing a face covering and social distancing.

Documents were posted as mandated on the bulletin board wall in the living room. The following Title 22 regulated areas were audited and found to be in compliance: Bedrooms contain the required furniture. The client’s bedrooms were inspected for safety, privacy, and comfort. The living areas are clean, bathrooms are clean and operational. The first aid kit is fully stocked with a manual, the hot water temperature was measured at 112 degrees Fahrenheit, the telephones are working, smoke and carbon monoxide detectors were in compliance, fire extinguishers are fully charged, medications were centrally stored and properly locked in the kitchen file cabinet and records are current, ample supply of perishable and nonperishable food, adequate linen supply, fire/emergency drill conducted on January 30, 2023. No firearms on the premises, the client's bedroom windows had no sliding window lock with thumbscrew, all exit doors were in compliance, covered trash cans, and no bodies of water were present. Hazardous items are inaccessible to clients, the yard is free of debris and hazards. The Licensee/Administrator Ms. Faulkner states staff was given training on dependent adult and elder abuse reporting.

There were no deficiencies cited. LPA Bunker provided Licensee/Administrator Ms. Faulkner with copies of the LIC809 and LIC809-C documents. Due to time constraints, LPA was unable to complete the visit and will return back at a later date to complete the visit.

Exit interview conducted.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

LIC809 (FAS) - (06/04)

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