198602258-12-10-2024-11-AS-PBUR-DBTNTF-20241210094440

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602258
Report Date: 11/21/2024
Date Signed: 12/10/2024 09:45:29 AM

Document Has Been Signed on 12/10/2024 09:45 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	VELMA'S GUEST HOME		FACILITY NUMBER:	198602258
ADMINISTRATOR/ DIRECTOR:	BAILEY, DENISE		FACILITY TYPE:	735
ADDRESS:	2824 W 108TH STREET		TELEPHONE:	(323) 757-7736
CITY:	INGLEWOOD	STATE: CA	ZIP CODE:	90303
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	11/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Cynthia Kaye Burford		TIME VISIT/ INSPECTION COMPLETED:	02:30 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 Licensing Cynthia Kaye Burford 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. Kaye 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 LIC802-C page 2

Stephanie Cifuentes	TELEPHONE: (323) 981-1755
Pamela Bunker	TELEPHONE: (323) 981-1755
	DATE: 11/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

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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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: 11/21/2024

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.

Licensee Kaye stated that her intention is to close this location and either transfer this facility to 10229 3rd Avenue, Inglewood, CA 90303 or surrender her license for Velma's Guest Home. She also stated that she currently has no clients and has not served any clients since 2018. LPA Bunker provided Licensee Kaye with detailed information regarding the procedures for facility relocation and closure.

There were no deficiencies cited.

An exit interview was conducted.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

LIC809 (FAS) - (06/04)

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