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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602414
Report Date: 11/06/2022
Date Signed: 11/06/2022 03:43:40 PM

Document Has Been Signed on 11/06/2022 03:43 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:PRISCILLA'S HOME 2FACILITY NUMBER:
198602414
ADMINISTRATOR:FIGUEROA, NEAL LOPEZFACILITY TYPE:
735
ADDRESS:1606 W 220TH STREETTELEPHONE:
(424) 536-3116
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 4CENSUS: 4DATE:
11/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Patrick FigueroaTIME COMPLETED:
12:46 PM
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On 11/06/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA met with the licensee Patrick Figueroa. LPA explained the purpose of today’s visit. The facility is licensed to operate for four (4) adults of which one (1) may be non-ambulatory ages 18 through 59 years of age. The clients are Harbor Regional Center consumers.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) client's rooms, two (1) common bathrooms, one (1) staff room, a living area, a dining area, a kitchen, and outside patio area.

LPA 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, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 109.4 degrees F. A comfortable temperature of 73 degrees 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 and not accessible to clients. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Fire extinguishers were fully charged, and smoke detectors and carbon monoxide were operable. A review of Medication Records Administration (MAR) and Fire Drills were observed to be maintained in order and accurate. The last fire drill was on 11/01/22. The facility has a working landline telephone. The First Aid Kit is maintained and in good condition. An analysis of the personnel files of staff members and the client's service records. The staff all had current First Aid/CPR certificates. Administrator's certificates were current at the facility. (Evaluation Report Continues on LIC 809-C)
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2022
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: PRISCILLA'S HOME 2
FACILITY NUMBER: 198602414
VISIT DATE: 11/06/2022
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INFECTION CONTROL:
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 wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). Posting of all mandatory inspection control posters was completed. The review of vaccination records, test results, and temperature monitoring for staff and residents. The facility has an approved CCLD Mitigation Plan.

No deficiencies were cited during this inspection visit.

An exit interview was conducted, and a copy of this report was provided to Patrick Figueroa.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2022
LIC809 (FAS) - (06/04)
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