198602627-3-27-2025-11-AS-EDAT-DF6QNW-20250327121948

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602627
Report Date: 03/27/2025
Date Signed: 03/27/2025 12:20:32 PM

Document Has Been Signed on 03/27/2025 12:20 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:	CALIFORNIA MENTOR - 230TH STREET HOME		FACILITY NUMBER:	198602627
ADMINISTRATOR/ DIRECTOR:	ROSAS, CLAUDIO		FACILITY TYPE:	735
ADDRESS:	434 W 230TH STREET		TELEPHONE:	(909) 483-2505
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY: 3		CENSUS: 2	DATE:	03/27/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:30 AM
MET WITH:	Nickie Southall		TIME VISIT/ INSPECTION COMPLETED:	12:31 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 March 27, 2025, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Program Executive Program Director Nickie Southall. LPA explained the purpose of today’s visit. The facility is licensed to operate for three (3) non-ambulatory ages 18 through 59. The clients are Harbor Regional Center consumers. The facility is a single-story structure located in a residential neighborhood. It consists of the following: three (3) client's rooms, two (2) common bathrooms, a living area, dining area, kitchen, and outside patio area. LPA toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for the client's 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. The water temperature measured 105.7 F. A comfortable temperature of 72 degrees was maintained in the facility. LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, and toxins are not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. A fire extinguisher was charged, smoke detectors and carbon monoxide were operable. A review of Medication Records Administration (MAR) and Fire Drills were observed to be maintained in order. The last fire drill was conducted on 09/06/24. Evaluation Report Continues on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Ernand Dabuet
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: CALIFORNIA MENTOR - 230TH STREET HOME	FACILITY NUMBER: 198602627
	VISIT DATE: 03/27/2025

NARRATIVE

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LPA observed screening protocols for visitors, staff, and residents and sanitizing stations in common areas and restrooms. The facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

An audit of clients #1 and #2 (C1 and C2) service files and staff #1 through #4 (S1 to S4) personnel files revealed that they were maintained in order and complete. A review of the client's P&I records showed they were complete and in order. The facility has current liability insurance coverage effective 10/01/24 through 10/01/25. A surety bond coverage, effective 06/15/22, remains valid as long as the CCL license is valid.

DEFICIENCIES:
From March 23 to March 29, 2025, an LPA identified on the Personnel Schedule. Staff member #4 had a cleared a criminal record but was not officially associated with the facility. This staff member was not transferred or connected to the CCL (Community Care Licensing) Guardian system, highlighting a critical oversight.

Deficiencies cited on LIC 809D.

An exit interview was conducted with Nickie Southall, and copies of the report were provided.

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Ernand Dabuet
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/27/2025 12:20 PM - It Cannot Be Edited

Created By: Ernand Dabuet On 03/27/2025 at 11:59 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: CALIFORNIA MENTOR - 230TH STREET HOME	FACILITY NUMBER: 198602627
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80019(f)(1)

80019 (f) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility...(1) A signed Criminal Background Clearance Transfer Request, LIC 9182 (Rev. 4/02) This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above. LPA identified staff #4 had criminal clearance background record, but was not criminal clearance transfer associated at this facility in Guardian System. The violation which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/28/2025
	Plan of Correction
1 2 3 4	LIcensee will ensure to do a Criminal Clearance Transfer Association for staff #4 in Guardian system. Plan of correction must be sent via email at ernand.dabuet@dss.ca.gov by due date 03/28/25.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:

	Ernand Dabuet
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025

LIC809 (FAS) - (06/04)

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