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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602619
Report Date: 01/13/2023
Date Signed: 01/13/2023 02:58:53 PM

Document Has Been Signed on 01/13/2023 02:58 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:ACOSTA FAMILY HOME IIIFACILITY NUMBER:
198602619
ADMINISTRATOR:ACOSTA, ASHLEYFACILITY TYPE:
735
ADDRESS:875 S ARANBE AVETELEPHONE:
(310) 554-4824
CITY:COMPTONSTATE: CAZIP CODE:
90220
CAPACITY: 6CENSUS: 2DATE:
01/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:17 PM
MET WITH:Anet Alegria-CaregiverTIME COMPLETED:
03:00 PM
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Licensing Program Analysts (LPAs) Martessa Brown and conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA had arrived and facility and no one was there. LPA contacted administrator. LPA met by Anet Alegria, DSP and the purpose of today’s visit was explained. The facility is licensed to serve 6 developmentally disabled clients (age 18-59). Of which 1 may be Non-Ambulatory.

There are currently (2) South Central Regional Center clients in placement. All (2) clients are ambulatory. The facility is a single-story structure located in a residential neighborhood. It consists of the following: 4 bedrooms, 3 bathrooms, family room/dining room, kitchen, living room, shaded area, indoor and outdoor activity area, laundry room and an attached garage.

LPA and staff toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were observed. Bed linens and comforters were stocked LPA did not observed enough bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured in bathroom #1 120 F, bathroom #2 1120.0 F and bathroom #3 125 F. A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is a enough perishable and non-perishable food available which is stored properly. Fire extinguisher was charged, smoke detectors and Carbon Monoxide were operable.

LIC 9099-C is on the next page
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2023
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ACOSTA FAMILY HOME III
FACILITY NUMBER: 198602619
VISIT DATE: 01/13/2023
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During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations ( Located in common areas and restrooms). LPA observed staff and residents were wearing face coverings, an isolation room and required postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.
During today’s visit LPA observed the following deficiencies. Deficiencies cited under California Code of Regulations Title 22.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023
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Document Has Been Signed on 01/13/2023 02:58 PM - It Cannot Be Edited


Created By: Martessa Brown On 01/13/2023 at 02:37 PM
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
MONTEREY PARK, CA 91754

FACILITY NAME: ACOSTA FAMILY HOME III
FACILITY NUMBER: 198602619

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. LPA observed in bedroom # 1 bathroom floor was not clean and window had dead bugs . Bedroom #1 window was missing screen. Also the bottom of the bed board had dusty with hair. Bedroom #2 bottom of the bedboard was had build up dusty and a lot of hair. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/25/2023
Plan of Correction
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Administrator will come with a plan on how she will keep facility clean and will send proof of correction via email to LPA by POC due date 1/25/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Martessa Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2023


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