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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602542
Report Date: 02/24/2022
Date Signed: 02/24/2022 11:59:00 AM

Document Has Been Signed on 02/24/2022 11:59 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME:CHELSEA RESIDENTIAL CAREFACILITY NUMBER:
198602542
ADMINISTRATOR:HARRISON, HONORAFACILITY TYPE:
735
ADDRESS:2030 W 144 STREETTELEPHONE:
(310) 515-4757
CITY:GARDENASTATE: CAZIP CODE:
90249
CAPACITY: 4CENSUS: 4DATE:
02/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Zoie Clark-LicenseeTIME COMPLETED:
12:15 PM
NARRATIVE
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On 2/24/22, Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA spoke with Administrator Zoie Clarke to conduct the covid-19 screener questionnaire and was informed the facility is free of Covid-19. LPA was met by Zoie Clarke and explained the purpose of today’s visit is the annual inspection visit concentrating on Infection Control Measure and was allowed entry into the facility. The facility is an ARF licensed for four (4) ambulatory client.

The facility is a single-story, 3-bedrooms, 2-bathroom home located in a residential neighborhood. It consists of the following: facility which included: Living room, dining area, kitchen, family room, laundry area, attached garage, shaded area, indoor/outdoor activity areas.

LPA and staff toured the physical plant. There were no bodies of water or obstructions on the premises. Beds and bedding supplies were in good condition, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. The kitchen was inspected and there is a 2-day supply of perishable and a 7-day supply of non-perishable food available, maintained properly. One fully charged fire extinguishers was found in dining room.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocol for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, a 30-day supply of Personal Protective Equipment (PPE) is available and sign in and out logs for visitors and staff are present in the facility.

Deficiencies Cited under California Code of Regulations Title 22 Division 6 Chapter 1 & 6, see attached 809-D's.

Advisories are on attached 9102-AN.

An exit interview was conducted, and a copy of this report was provided to Zoie Clarke Administrator.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2022
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 6
Document Has Been Signed on 02/24/2022 11:59 AM - It Cannot Be Edited


Created By: Stephanie Cifuentes On 02/24/2022 at 11:09 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: CHELSEA RESIDENTIAL CARE
FACILITY NUMBER: 198602542

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above as LPA Cifuentes observed bleach in under sink cabinet in master bathroom which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/25/2022
Plan of Correction
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POC cleared during visit. LPA observed staff remove bleach from cabinet and put it in locked cabinet under sink.
Type A
Section Cited
CCR
80087(g)(1)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. LPA Cifuentes observed a knife in an unlocked kitchen cabinet, which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/25/2022
Plan of Correction
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POC cleared during visit. Staff immediately placed knife in locked cabinet.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Eva M Alvarez
LICENSING EVALUATOR NAME:Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 02/24/2022 11:59 AM - It Cannot Be Edited


Created By: Stephanie Cifuentes On 02/24/2022 at 11:09 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: CHELSEA RESIDENTIAL CARE
FACILITY NUMBER: 198602542

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. LPA observed that the overhead lights in bedrooms 1, 2 and master are not operational, which poses a potential safety or personal rights risk to persons in care.
POC Due Date: 03/10/2022
Plan of Correction
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POC cleared during visit. Licensee had bulbs replaced and in all three bedrooms.
Type B
Section Cited
CCR
80088(c)
Fixtures, Furniture, Equipment, and Supplies
(c) Fireplaces and open-faced heaters shall be inaccessible to clients to ensure protection of the clients' safety.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the fireplace in living room was not properly screened, which poses/posed a potential health and safety risk to persons in care.
POC Due Date: 03/10/2022
Plan of Correction
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Licensee will purchase a metal screen to cover fireplace, and submit proof of correction to CCLD via email or fax by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Eva M Alvarez
LICENSING EVALUATOR NAME:Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022


LIC809 (FAS) - (06/04)
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