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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602414
Report Date: 09/09/2024
Date Signed: 09/09/2024 11:52:45 AM

Document Has Been Signed on 09/09/2024 11:52 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:PRISCILLA'S HOME 2FACILITY NUMBER:
198602414
ADMINISTRATOR/
DIRECTOR:		FIGUEROA, NOUYNA QUIWAFACILITY TYPE:
735
ADDRESS:1606 E 220TH STREETTELEPHONE:
(424) 536-3116
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 4CENSUS: DATE:
09/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:53 AM
MET WITH:Noel & Novyna FigueroaTIME VISIT/
INSPECTION COMPLETED:
12:14 PM
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On 09/09/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with DSP Noel Figueroa and administrator Novyna Figueora. LPA explained the purpose of today’s visit. The facility is licensed to operate for (4) ambulatory adults of which (1) may be non-ambulatory ages 18 - 59. The residents are all Harbor Regional Center clients.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: (4) clients' rooms, (1) bathroom, (1) staff bathroom, (1) staff bathroom, a living area, a dining area, a kitchen, an office, an outside seating area, and a garage.

LPA toured the physical plant with Noel Figueroa. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 118.9 degrees F. A comfortable temperature of 73 degrees F. was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. A fire extinguisher was charged. A review of the Medication Records Administration (MAR) was observed to be maintained in place.

(Evaluation Report continues LIC 809-C)


Surety Bond Bond # 71800059 Fire Drill 08/01/24
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2024
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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: PRISCILLA'S HOME 2
FACILITY NUMBER: 198602414
VISIT DATE: 09/09/2024
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA observed First Aid Kit was maintained. A working landline phone was operational. The last fire drill was conducted on 08/01/24. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current liability insurance on file effective 07/07/24 - 07/07/25. The facility is current on Community Care Licensing annual dues. The facility has an effective Surety Bond Bond # 71800059.

An audit of client #1-#4 (C1-C4) service files and staff #1-# (S1-S4) personnel files revealed to be complete. An audit of the client's P&I is maintained in order and complete. The facility has the current administrator's certification on file for Patrick Figueroa #7021036735 Expiration 11/24/2025 and Novyna Q. Figueroa 7004354735 Expiration: 06/17/26.

No deficiencies during this inspection visit.

An exit interview was conducted with Novyna Q. Figueroa and a copy of the report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024
LIC809 (FAS) - (06/04)
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