198602258-10-8-2023-11-AS-PBUR-CWF77D-20231008212434

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602258
Report Date: 10/03/2023
Date Signed: 10/08/2023 09:25:00 PM

Document Has Been Signed on 10/08/2023 09:25 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:	VELMA'S GUEST HOME		FACILITY NUMBER:	198602258
ADMINISTRATOR:	BAILEY, DENISE		FACILITY TYPE:	735
ADDRESS:	2824 W 108TH STREET		TELEPHONE:	(323) 757-7736
CITY:	INGLEWOOD	STATE: CA	ZIP CODE:	90303
CAPACITY: 6		CENSUS: 0	DATE:	10/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	07:48 AM
MET WITH:	Kishuna Galbreath		TIME COMPLETED:	12:45 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 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 was properly screened for COVID-19 symptoms and temperature was checked. LPA Bunker met with Associate Director Kishuna Galbreath and spoke to Licensee Cynthia Kaye Buford via telephone and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved mitigation plan report. There are currently no Westside Regional Center (WRC) clients in placement, for the Adult Residential Facility (ARF). The facility's annual fees are current. Licensee Ms. Buford stated all clients have been relocated as of February 2018 to a Supportive Living Home with WRC in which she is a practicing vendor. There are 12 Domains in the Infection Control Practices that will be observed and reviewed. "I 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-story family home located in a residential neighborhood. Ms. Kishuna and LPA Bunker made a complete tour of the facility which included: Living room, dining room, family room, office, kitchen, breakfast area, pantry, 5 bedrooms, 4 bathrooms, laundry room, storage room, detached garage, patio/shaded area, indoor/outdoor activity areas. See continued page 2

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

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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Document Has Been Signed on 10/08/2023 09:25 PM - It Cannot Be Edited

Created By: Pamela Bunker On 10/03/2023 at 12:32 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: VELMA'S GUEST HOME	FACILITY NUMBER: 198602258
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85088(c)(2)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	85088 (c) (1) (2) Fixtures, Furniture, Equipment, and Supplies: The licensee shall ensure client rooms have furniture, equipment, and supplies. During the facility tour, we observed bedrooms, 1, 3, and 4, and noticed the absence of clients' bedroom furniture in these rooms. Three of the bedrooms had been converted into office spaces without prior approval. This violation poses a potential health, safety, or personal rights risk to persons in care.
	POC Due Date: 11/03/2023
	Plan of Correction
1 2 3 4	The licensee will submit the necessary documents to officially convert the designated rooms into office spaces, reducing the facility's overall capacity. By the POC due date of 11/03/2023.

Type B

Section Cited

CCR

80010(a)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	80010 (a) (b) Limitations on Capacity and Ambulatory Status: A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including the capacity limitation. Client rooms approved for ambulatory clients only shall not be used for office space. This violation poses a potential health, safety, or personal rights risk to persons in care.
	POC Due Date: 11/03/2023
	Plan of Correction
1 2 3 4	The licensee needs to submit a formal written plan outlining the Limitations on Capacity and Ambulatory Status: That the licensee operates the facility strictly within the defined conditions and limitations of its capacity. By the POC due date of 11/03/2023.

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:

Stephanie Cifuentes

LICENSING EVALUATOR NAME:

Pamela Bunker

LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: VELMA'S GUEST HOME	FACILITY NUMBER: 198602258
	VISIT DATE: 10/03/2023

NARRATIVE

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Continued LIC809-C page 2

Documents were posted as mandated on the wall in the kitchen and breakfast area. The following Title 22 regulated areas were audited and found to be in compliance: Bedroom 2 contains the required furniture, and the bathrooms are clean and operational. Personal accommodations were observed for safety, privacy, comfort, and non-skid surface mats. The kitchen was observed for its ability to prepare and serve food. The food service was reviewed for appropriate quantity and proper storage; there was an ample supply of perishable and nonperishable food. The resident’s medications were reviewed for proper storage, documentation, and system implementation. Medications are locked, and records are current. Common areas observed for the ability to safely serve the needs of the residents, including cleanliness, and clear of any potential hazards to the residents. The first aid kit is fully stocked with manual, smoke, and carbon monoxide detectors were in compliance, the hot water temperature was measured at 115 degrees Fahrenheit within the normal limits (105-120F degrees), the fire extinguisher is fully charged, adequate linen supply, the facility telephones are working, resident. The client's bedroom windows have no sliding window lock with thumbscrews, all exit doors were in compliance, the yard was free of debris hazards, and trash cans were covered. Staff was given training on dependent adult and elder abuse reporting.

There were no deficiencies cited.

An exit interview was conducted.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

LIC809 (FAS) - (06/04)

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