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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602627
Report Date: 03/29/2023
Date Signed: 04/21/2023 10:56:12 AM

Document Has Been Signed on 04/21/2023 10:56 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:CALIFORNIA MENTOR - 230TH STREET HOMEFACILITY NUMBER:
198602627
ADMINISTRATOR:ROSAS, CLAUDIOFACILITY TYPE:
735
ADDRESS:434 W 230TH STREETTELEPHONE:
(909) 483-2505
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 3CENSUS: 3DATE:
03/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Kristina MoralesTIME COMPLETED:
02:42 PM
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On 03/29/23, Licensing Program Analyst (LPA) Lizeth Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with caregiver Kristina Morales and the purpose of today’s visit was explained. The facility is licensed to serve three (3) non- ambulatory residents ages 18 through 59. The residents are Harbor Regional Center Department of Mental Health residents.

The facility is a single-story home and consists of the following: three (3) client bedrooms, two (2) bathrooms one (1) of which is for residents and one (1) is for visitors and staff, staff working area, living room, kitchen, laundry area, dining room, attached garage which houses an additional refrigerator for extra food storage and an outdoor shaded area.

LPA conducted a records review of three (3) residents records, zero (0) staff records as they were unavailable during visit, three (3) residents Personal & Incidental Records and reviewed the facility disaster plan. The Last fire drill was in December 2022. All resident records were complete. LPA reviewed (3) Client Medication Administration Records and did not observed any discrepancies at the time of visit.

All resident rooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed, walls and floors were clean and in good repair, bed linens, comforters and bath towels were fully stocked. Bathrooms were found to be within Title 22 regulation, toilets and water faucets worked properly, shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature properly measured between 105-120F, bathroom #1 was 114.3F & bathroom #2 was 112.3F, kitchen sink was 117.5F

Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide and smoke detectors are interconnected and operable. Two (2) fire extinguishers were fully charged, one (1) located and mounted in the entry way and the second (2) in the kitchen, toxins and knifes

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2023
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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Document Has Been Signed on 04/21/2023 10:56 AM - It Cannot Be Edited


Created By: Lizeth Villegas On 03/29/2023 at 01:45 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: CALIFORNIA MENTOR - 230TH STREET HOME
FACILITY NUMBER: 198602627

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(e)(1)

Personnel records All personnel records shall be maintained at the facility site and shall be available to the licensing agency for review.

The licensee shall be permitted to retain such records in a central administrative location provided that they are readily available to the licensing agency at the facility site as specified in Section 80066(c).
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above as the administrator did not have staff files at the facility ad was unable to provide them during the visit which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/07/2023
Plan of Correction
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Licensee shall ensure that staff records are made avaible to licensing agency during regular business hours, licensee shall submit a statement acknowledging title 22 regulations by POC due date.
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:Janae Hammond
LICENSING EVALUATOR NAME:Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/21/2023 10:56 AM - It Cannot Be Edited


Created By: Lizeth Villegas On 03/29/2023 at 02:00 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: CALIFORNIA MENTOR - 230TH STREET HOME
FACILITY NUMBER: 198602627

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80023(d)
80023 Disaster and mass casualty plan
Disaster drills shall be conducted at least every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above as licensee failed to conduct disaster drills regulary which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/07/2023
Plan of Correction
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Licensee to conduct drill and submit proff to LPA by POC due date.
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:Janae Hammond
LICENSING EVALUATOR NAME:Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2023


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: CALIFORNIA MENTOR - 230TH STREET HOME
FACILITY NUMBER: 198602627
VISIT DATE: 03/29/2023
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were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked, first aid manual up to date. A landline was observed, one (1) cordless phone located at the staff working area and one (1) cordless phone located in the kitchen. Outside grounds were toured and no bodies of water were observed. Exits/ Walkways around the home were free of debris and hazards.

During today’s visit LPA observed deficiencies documented on 809 D(s)

Exit interview conducted with caregiver Kristina Morales, appeal rights discussed, and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023
LIC809 (FAS) - (06/04)
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