198602568-12-12-2023-11-AS-SLEO-CYFUAE-20231212142438

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602568
Report Date: 12/12/2023
Date Signed: 12/12/2023 02:24:52 PM

Document Has Been Signed on 12/12/2023 02:24 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	MOM & DAD'S HOUSE-COTTAGE		FACILITY NUMBER:	198602568
ADMINISTRATOR:	MEADER, IVONNE A		FACILITY TYPE:	740
ADDRESS:	5413 E CONANT ST		TELEPHONE:	(949) 381-1792
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90808
CAPACITY:	6	CENSUS: 6	DATE:	12/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	IVONNE A. MEADER - Licensee/Administrator		TIME COMPLETED:	02:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 12/12/2023 at around 10:00 AM, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with Licensee/Administrator Ivonne A. Meader. LPA explained the purpose of the visit and was accompanied by the Administrator inside and outside the facility during this inspection. This facility is licensed to serve 6 non-ambulatory adults ages 60 and above, of which 6 may be in hospice care. A total of 6 non-ambulatory residents are currently residing in this facility. The Annual Licensing Fees are current. The facility is a two-story house located in a residential street. The first floor consists of 6 resident bedrooms, 2 resident bathrooms, 2 resident toilet rooms, 1 living/entry room, 1 dining/tv/activity room, 1 kitchen, 1 detached garage, 1 laundry closet, and 2 hallway closets. The second floor consist of 1 staff bedroom, 2 staff bathrooms, 1 office room. The outside premises consist of several outside shaded seating areas in the front and backyard. Outside grounds were toured and no bodies of water were observed. The patio furniture is under a shaded area and accessible to residents. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. LPA toured the kitchen area and observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept in locked storage cabinet.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: MOM & DAD'S HOUSE-COTTAGE	FACILITY NUMBER: 198602568
	VISIT DATE: 12/12/2023

NARRATIVE

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LPA observed that medications were safe, locked, and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Documents are posted as mandated. Last fire, earthquake, and disaster drill was conducted on 9/28/2023. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational. There are several fire extinguishers on the premises, and they were last serviced on 09/14/2023. There is a videoconferencing device (ipad) dedicated for client use in the dining/tv/activity room.

6 out of 6 resident’s bedrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries accessible to residents. LPA tested hot water temperature and it measured between 105 and 120 degrees Fahrenheit. This facility provides residents with hygiene products such as feminine napkins, nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb.

5 staff records were reviewed, 5 out of 5 staff records had current First Aid Certificates, Criminal Record Clearance, Job Applications, Tuberculosis Test, Facility Trainings/Drills, and signed Employee Rights.

5 resident records were reviewed and, 5 out of 5 resident records had Admission Agreements, Medical Assessments, Consent Forms, Weight Record, Emergency Information, Appraisal & Needs Service Plan, Tuberculosis Test, Centrally Stored Medication Destruction Record, and Personal Rights.

No deficiencies are being cited based on LPA observations, interviews conducted and record review in accordance with the California Code of Regulations, Title 22.

An exit interview was conducted and a copy of this report was left with the Administrator

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

LIC809 (FAS) - (06/04)

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