198602236-12-14-2024-11-AS-SLEO-DBXUPK-20241214144541

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602236
Report Date: 12/14/2024
Date Signed: 12/14/2024 02:45:54 PM

Document Has Been Signed on 12/14/2024 02:45 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	LADERA HOMES I		FACILITY NUMBER:	198602236
ADMINISTRATOR/ DIRECTOR:	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	TOTAL ENROLLED CHILDREN: 0	CENSUS: 3	DATE:	12/14/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:20 AM
MET WITH:	LIcensee/Administrator - Renee Faulkner		TIME VISIT/ INSPECTION COMPLETED:	03:00 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 12/14/2024 around 9:20 AM, the California Department of Social Services (CDSS) – Community Care Licensing Division (CCLD) staff conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with Administrator/Licensee, Renee Faulkner. CCLD staff explained the purpose of the visit and was accompanied by a staff member inside and outside the facility during this inspection. This facility is licensed to serve 5 ambulatory adults ages 55 and above, of which 2 maybe on hospice. A total of 3 residents are currently residing in this facility. The Annual Licensing Fees are current. Facility Layout: The facility is a one-story house located on a main residential street. The home consists of 4 resident bedrooms, 1 full bathroom, 1 toilet room, 1 kitchen area, 1 laundry area, 1 living room area, 1 community room area with a dinning table, office area, and activity table, 1 backyard area with a table and seats, and 1 attached garage.

Ulysses Coronel	TELEPHONE: (323) 981-1755
Socorro Leandro	TELEPHONE: 323-981-1755
	DATE: 12/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2024

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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Document Has Been Signed on 12/14/2024 02:45 PM - 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: LADERA HOMES I	FACILITY NUMBER: 198602236
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Medical Assessment

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 3 out 3 resident records did not their Tuberculosis Test Results and 1 out 3 resident records did not have their Physical Examination, which poses a potential health or safety risks to persons in care.
	POC Due Date: 01/14/2025
	Plan of Correction
1 2 3 4	The licensee has agreed to email Tuberculosis Test Results for all residents and 1 resident's physical exam. Socororro.Leandro@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.

Ulysses Coronel	TELEPHONE: (323) 981-1755
Socorro Leandro	TELEPHONE: 323-981-1755
	DATE: 12/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2024

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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: LADERA HOMES I	FACILITY NUMBER: 198602236
	VISIT DATE: 12/14/2024

NARRATIVE

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Outside Grounds: were toured no bodies of water were observed, walkways around the home were clear of hazards, and there are security bars on the back windows but not on the resident bedroom windows.

Kitchen Area/Facility Food: The facility has supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives were kept inaccessible to residents in care. There is fire extinguisher in the kitchen area.

Living Room/Community Room: There is a landline telephone, videoconferencing device, and games/activity work (i.e puzzles) for residents in the community room area. There are sofas and a large television in the living room.

Resident Bedrooms: 4 out of 4 resident bedrooms were toured. There is adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition.

Bathrooms: Toilets, showers, and water faucets worked, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries accessible to residents.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2024

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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: LADERA HOMES I	FACILITY NUMBER: 198602236
	VISIT DATE: 12/14/2024

NARRATIVE

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Medications: were inaccessible to residents in care. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. 3 out of 3 Medication Administration Records (MARs) were reviewed and they were current and up to date.

Miscellaneous: Documents are posted as mandated. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational. The last Disaster Drill was conducted on 01/30/2023.

5 staff records were reviewed, 5 out of 5 staff records had required documentation.

3 resident records were reviewed and, 3 out 3 resident records did not have their Tuberculosis Test Results and 1 out of 3 resident records did not have their Physicians Report (Physical Exam).

A technical advisor is being provided regarding removing facility small refrigerator and facility file cabinet from a resident’s bedroom. The licensee has agreed to find a new place for the items.

A deficiency is being cited based on record review in accordance with the California Code of Regulations, Title 22, see LIC809D. A violation regarding resident records.
An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Licensee.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2024

LIC809 (FAS) - (06/04)

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