198602263-10-6-2023-11-AS-EGOZ-CWCSND-20231006140122

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602263
Report Date: 10/06/2023
Date Signed: 10/06/2023 02:01:28 PM

Document Has Been Signed on 10/06/2023 02:01 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:	NP CARE HOME		FACILITY NUMBER:	198602263
ADMINISTRATOR:	TATUM, RONIC		FACILITY TYPE:	740
ADDRESS:	3767 VIRGINIA ROAD		TELEPHONE:	(323) 205-5145
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90016
CAPACITY:	6	CENSUS: 6	DATE:	10/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:33 AM
MET WITH:	Ronic Tatum		TIME 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	On 10/06/23, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced annual required visit using the Care Inspection Tool. LPA was first greeted by Caregiver Lakisha Whetstone then was joined with administrator Ronic Tatum and explained the purpose of today’s visit. The facility is licensed to operate for six (6) non-ambulatory of which one (1) may be bedridden of elderly residents ages 60 and above. The facility is approved for two (2) hospice residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: three (3) resident's rooms, two (2) common bathrooms, one (1) staff bathroom, living area, dining area, kitchen, outside covered patio area, and a laundry room. A garage is being used for storage and office space. LPA and administrator 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, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 109.3 in bathroom number one (1) and 114.3.8 F in bathroom number two (2). A comfortable temperature was maintained in the facility. LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored, yet accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available, maintained properly. A fire extinguisher was charged, six (6) smoke detectors and carbon monoxide were operable. The facility has a working landline telephone and the last fire drill was conducted on September 2023. See LIC809-C

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elvira Gonzalez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: NP CARE HOME	FACILITY NUMBER: 198602263
	VISIT DATE: 10/06/2023

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
26
27
28
29
30
31
32

During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff residents were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has an approved Mitigation Plan Report with CCLD.

No deficiencies were cited during this inspection visit.

An exit interview was conducted and a copy of this report was provided to Ronic Tatum.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elvira Gonzalez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2