198602266-8-8-2023-11-AS-PBUR-CUHM9Z-20230808092531

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602266
Report Date: 08/01/2023
Date Signed: 08/08/2023 09:25:59 AM

Document Has Been Signed on 08/08/2023 09:25 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	GOSSETT RESIDENTIAL SERVICES INC. #2		FACILITY NUMBER:	198602266
ADMINISTRATOR:	GOSSETT, LOUISE		FACILITY TYPE:	735
ADDRESS:	1939 WEST 79TH ST		TELEPHONE:	(323) 751-4964
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90047
CAPACITY: 4		CENSUS: 3	DATE:	08/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Regina Johnson		TIME COMPLETED:	03:30 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 Administrator Regina Johnson and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved mitigation plan report. The facility is vendored with South Central Los Angeles Regional Center (SCLRC). LPA Bunker verified that the administrator is present at the property 20+ hours per week, and all current staff was fingerprinted and cleared/associated with the facility. The facility's annual fees are current. The facility currently has three (3) ambulatory South Central Los Angeles Regional Center (SCLARC) consumers in placement. The following Domains will be observed and reviewed: Infection Control, Physical Plant & Environmental, Operational Requirements, Staffing, Personnel Records-Training, Client Rights-Information, Client Rights-Information, Client Records-Incident Reports, Food Service, Health-Related Services, Incidental Medical Services, Disaster Preparedness, and Emergency Intervention. "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-story family home located in a residential neighborhood. Ms. Johnson and LPA Bunker made a complete tour of the facility which included: Living room, dining room, kitchen, breakfast nook, 3 bedrooms, 2 bathrooms, laundry room, detached garage, patio/shaded area, and indoor/outdoor activity areas. Bedrooms 1 and 3 are designated as client's bedrooms. Each bedroom has two clients to a room. Bedroom 2 is designated for living in staff. See continued LIC812-C page 2

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

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: GOSSETT RESIDENTIAL SERVICES INC. #2	FACILITY NUMBER: 198602266
	VISIT DATE: 08/01/2023

NARRATIVE

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Continued LIC809-C page #2

Documents were posted as mandated on the bulletin board wall in the hallway and kitchen. 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 112.5 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 dining room file cabinet and records are current, ample supply of perishable and nonperishable food, adequate linen supply, fire/emergency drill conducted on May 13, 2023. No firearms on the premises, the facility has security bars on the windows with a security release mechanism, the client's bedroom windows have no sliding window lock with thumbscrew, all exit doors were in compliance, covered trash cans, and no bodies of water present. Hazardous items are inaccessible to clients, the yard is free of debris and hazards. The administrator states staff was given training on dependent adult and elder abuse reporting. The administrator certificate is current and expires on 02/21/2024, and HIV/TB certification is also current.

There were no deficiencies cited. LPA Bunker provided Administrator Regina Johnson with copies of the LIC809, LIC809-C, LIC858, and LIC859 documents.

Exit interview conducted.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

LIC809 (FAS) - (06/04)

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