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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602568
Report Date: 10/09/2024
Date Signed: 10/09/2024 04:38:40 PM


Document Has Been Signed on 10/09/2024 04:38 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245



FACILITY NAME:MOM & DAD'S HOUSE-COTTAGEFACILITY NUMBER:
198602568
ADMINISTRATOR:MEADER, IVONNE AFACILITY TYPE:
740
ADDRESS:5413 E CONANT STTELEPHONE:
(949) 381-1792
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY:6CENSUS: 5DATE:
10/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:51 AM
MET WITH:Ivonne Meader, AdministratorTIME COMPLETED:
12:30 PM
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On 10/09/2024 at 8:45am, Licensing Program Analyst (LPA) Zina Brown conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the one (1) year annual inspection. LPA met with Ivonne Meader (Administrator) and the purpose of the visit was discussed. Facility is licensed to serve 6 non-ambulatory residents and an approved for six (6) hospice waivers. The five (5) of the residents are diagnosed with dementia, zero (0) hospice, one (1) home health resident and zero (0) bedridden resident. The facility have a balance of $0 for annual fees. The last fire drill was conducted on 09/22/2024
The Certificate of Liability is valid from 08/15/2024 - 08/15/2025.

The facility is a two (2) story home consisting of: (6) resident bedrooms, (2) Full bathroom, (2) resident toilet rooms, (1) living/entry room, (1) dining room/tv/activity room, (1) kitchen, (1) detached garage with extra refrigerator for staff and 330 meals which expires in 20 years, (1) laundry room, and (2) hallway closets. The second floor consist of (1) staff bedroom, (2) staff bathrooms and (1) office room. The outside of the facility provides an (3) outdoor shaded area with a front and backyard.

LPA toured the resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured at 106.0 F (bathroom #1), 112.3 F (bathroom #2), 109.6 (half-bathroom #1), 108.0F (half bathroom #2) and 115.1F (kitchen). Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions.

Report continues on LIC809-C

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Zina BrownTELEPHONE: 424-544-1075
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2024
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: MOM & DAD'S HOUSE-COTTAGE
FACILITY NUMBER: 198602568
VISIT DATE: 10/09/2024
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Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly, and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

LPA conducted a electronic records review of (5) client records, (5) staff records, and reviewed the facility disaster plan. All client & staff records were organized, and completely up to date . The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (5) Client Medication Administration Records and did not observed any discrepancies at the time of visit.

During todays visit LPA did not observe any deficiencies and an exit interview conducted with Ivonne Meader, Administrator

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Zina BrownTELEPHONE: 424-544-1075
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024
LIC809 (FAS) - (06/04)
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