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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602399
Report Date: 04/18/2024
Date Signed: 04/18/2024 05:36:47 PM

Document Has Been Signed on 04/18/2024 05:36 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SAMOLINE GUEST HOMEFACILITY NUMBER:
198602399
ADMINISTRATOR/
DIRECTOR:		TAWFIK, MAGDYFACILITY TYPE:
735
ADDRESS:11528 SAMOLINE STREETTELEPHONE:
(562) 923-7661
CITY:DOWNEYSTATE: CAZIP CODE:
90241
CAPACITY: 6CENSUS: 6DATE:
04/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Gamal TawfikTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced visit at the facility for the purpose of conducting the required annual inspection. LPA utilized the Compliance and Regulatory Enforcement (CARE) Tool to evaluate the facility. LPA Gonzalez met with Assistant Administrator Gamal Tawfik and explained the purpose for the visit.

The facility is licensed to serve (6) ambulatory clients ages 18 to 59 years old. Facility is operating within the approved capacity. Currently, there are six (6) clients in placement, and (0) clients with a restricted health care condition. All clients residing at this facility receive case management services provided by South Central Los Angeles Regional Center.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical Services, Disaster Preparedness, and Emergency Intervention.


During the visit LPA observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor screening station at the entrance of the facility. The facility has a plan in place to designate a facility room as a COVID-19 isolation room if needed. An Infection Control Plan and COVID-19 Mitigation Plan was reviewed.


Refer to LIC 809C for continuation of report
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SAMOLINE GUEST HOME
FACILITY NUMBER: 198602399
VISIT DATE: 04/18/2024
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Operational Requirements: Fire Drills are conducted every other month, the last fire drill was conducted on 3/18/24. Emergency Disaster/ Earthquake Drills are also conducted every other month and the last one was conducted on 3/18/2024. Facility Administrator is adhering to operational requirements.

Physical Plant & Environment Safety: The facility is a single story house located in a residential area which consists of a This single-story home contains three (3) clients bedrooms, one (1) staff bedroom, two (2) bathrooms, a living room, kitchen, dining area, backyard with patio, and attached garage. here is a large, covered patio area. Bathrooms are clean and operational. All client rooms were checked. All clients beds have the required linens which were in good condition at the time of the visit. All bedrooms had sufficient closet/ storage space. Facility toilets and water faucets worked properly. Shower was free of mold/mildew, adequate lighting, and sufficient toiletries are accessible to clients. Water temperature properly measured at 120F*. Facility temperature was comfortable throughout the facility. LPA observed the facility to be clean and in good repair. First aid kit is fully stocked with manual, smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to clients. Hazardous toxins and/or items are inaccessible to clients, fire extinguisher is fully charged. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. A shaded area with seating is provided for clients in the backyard of the facility

Staffing: There is sufficient staffing at the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed (3) staff files. Staff have current CPR/first aid training and sufficient on-going training that meets the annual requirement. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting. Administrator Certificate is current and expires on 03/08/25.


Refer to LIC 809C for continuation of report
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SAMOLINE GUEST HOME
FACILITY NUMBER: 198602399
VISIT DATE: 04/18/2024
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Client Rights-Information: Client personal rights and House Rules are posted. Per Facility Assistant Administrator, facility provides wi-fi services for facility clients.

Client Records-Incident Reports: Four (4) client files were reviewed containing admission agreements, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment, Appraisal Needs and Services Plan, Functional Capabilities Assessment, Mental Health Intake Assessment, Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights and current IPPs.

Food Service: The facility has sufficient food supplies of 2-day perishable and 7 day supply of non-perishable items. The food is properly stored in the refrigerator which is clean and well-maintained. There are no clients that follow a special diet residing at this facility. Kitchen is kept clean and free from rodents and other bugs/ insects. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services: The medications are centrally stored and in their original containers. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubble packed and delivered monthly.

Incidental Medical Services: Per Facility Administrator, there are no clients at this home with incidental medical services nor any client that has a restricted health condition.

Disaster Preparedness: The facility has an Emergency Disaster Plan readily accessible. A posted Emergency Disaster Plan LIC 610D containing emergency evacuation, storage and preservation of medications, operation of manual assist devices,

Emergency Intervention : No manual restraints or seclusion are used with clients in care.


No deficiencies/ citations noted. Exit interview and a copy of this report was provided to Assistant Administrator Gamal Tawfik.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
LIC809 (FAS) - (06/04)
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