198602406-9-8-2022-11-AS-PSCT-CJ3QEK-20220908120629

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602406
Report Date: 09/08/2022
Date Signed: 09/08/2022 12:06:55 PM

Document Has Been Signed on 09/08/2022 12:06 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	ALABASTER ELDERLY CARE		FACILITY NUMBER:	198602406
ADMINISTRATOR:	DAVIS, DELORES		FACILITY TYPE:	740
ADDRESS:	9825 8TH AVENUE		TELEPHONE:	(323) 971-2964
CITY:	INGLEWOOD	STATE: CA	ZIP CODE:	90305
CAPACITY:	6	CENSUS: 4	DATE:	09/08/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Delores Davis		TIME COMPLETED:	12:20 PM

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On 09/08/22, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced Annual Required visit with a primary focus on infection control measures. Upon arrival at the facility, LPA met with administrator Delores Davis and conducted a risk assessment. Based on the assessment, the facility is clear of Covid-19 infection. LPA was granted access and allowed to enter the facility to conduct the inspection, and the purpose of the visit was explained. LPA was properly screened for Covid-19 symptoms and temperature was checked and logged in the visitor’s book.

The facility is licensed to serve age range 60 and over; with a capacity of six (6). Approved for three ambulatory (3) and three (3) non-ambulatory residents; with a hospice waiver for three (3). Currently there are four (4) residents in care. The facility has (2) Non-ambulatory Residents and (2) Ambulatory Residents. There are two shared bathrooms and three bedrooms. Facility Carbon Monoxide and Smoke Detectors were tested. All alert systems are working properly. The facility has two (2) Fire Extinguishers that were fully charged. Last fire drill was completed on 07/21/22.

During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance. PPE supplies are readily available to staff, and additional supplies are stored. Sufficient paper, cleaning, and disinfecting supplies were observed. The facility’s designated visitation area is in the front living room. LPA observed staff wearing face coverings. LPA also observed covid postings throughout the facility. LPA observed the facility has a 90-day supply of Personal Protective Equipment (PPE).

Report continued LIC 809-C

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

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: ALABASTER ELDERLY CARE	FACILITY NUMBER: 198602406
	VISIT DATE: 09/08/2022

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LPA Scott toured the facility with administrator Davis including but not limited to common living spaces, residents’ bedrooms, bathrooms, kitchen, living room, media room, laundry area with washer and dryer, garage, and backyard. The facility is clean and in good repair, bedrooms are furnished with beds with bedding, a chair, lamps, and a dresser. The bathrooms had non-skid mats and grab bars. All bathroom fixtures are clean, in good repair, and working properly. Toiletries are accessible to residents. LPA checked the water temperature and it measured at 107.6 f. All toxins and knives are locked/secured and inaccessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available.

During the visit, LPA observed the following to be complying: the facility's infection control practices; screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms; every staff was wearing a face covering; the facility has a 60-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has a Mitigation Plan Report approved by CCLD.

No deficiencies were cited on this annual visit.

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to facility administrator Delores Davis.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

LIC809 (FAS) - (06/04)

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