198602890-7-14-2023-28-AS-JBAE-CTQS9N-20230714134100

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602890
Report Date: 07/14/2023
Date Signed: 07/14/2023 01:41:06 PM

Document Has Been Signed on 07/14/2023 01:41 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	J AND C HOUSE OF LOVE		FACILITY NUMBER:	198602890
ADMINISTRATOR:	WISE, CHANTE		FACILITY TYPE:	740
ADDRESS:	12121 164TH STREET		TELEPHONE:	(562) 229-9957
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY:	6	CENSUS: 6	DATE:	07/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Administrator Chante Smith		TIME COMPLETED:	02:00 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 7/23/23 at 8:30 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Annual/Required inspection to J and C House of Love. Upon arrival LPA was greeted by Direct Support Professional (DSP) Lakaya Buckhalter who contacted the Administrator, Chante Smith, at 9:35 a.m. LPA explained the reason for the visit to both staff and Administrator. This home is licensed to serve age range 60 and over: approved for 6 Non-Ambulatory of which three may be hospice residents. There were (6) clients in care during the time of this visit. The last emergency disaster/fire drill was conducted on 7/05/23. The Administrator Certificate expires on 10/08/2023 #6027733740. During today's visit LPA inspected the physical plant inside and outside, reviewed the food supply, tested the smoke/carbon monoxide detectors, reviewed (3) staff files, (6) resident files, medications, and medication administration records for (6) residents. This home contains 4 bedrooms,1 staff bedroom, 3 bathrooms, 1 staff bathroom, living room, laundry room, kitchen, dining room and an attached garage. LPA toured the physical plant with the DSP Lakyaya Buckhalter, and observed all (4) client bedrooms, contained required furniture, lamps, dresser, chair, and closet space. The three bathrooms contain a working toilet, basin and water faucet, walk in shower with grab bar, and shower chair. The temperature measured at 115.3F-116.7F. The smoke detectors were battery operated. tested and observed to be working properly. The carbon monoxide detector is located in the hallway, tested, and functioning properly. There were (1) fire extinguishers located in kitchen fully charged and up to date. The kitchen was toured and contained working appliances; refrigerator, stove, oven and contained dishware, cups, plates, utensils, pots, and pans. The knives were unsecured/unlocked in the kitchen. The cleaning agents and toxins was also unsecured and unlocked under the sink. Staff stated the locks is broken. The Administrator stated they planned on replacing the locks today 7/14/2023. The pantry was well stocked with canned goods, pasta, cereals, and the food supply contained a sufficient supply with a two-day supply of perishables and a seven-day supply of non-perishables that met title 22 guidelines. Walls and floors, cabinets and counters were clean and sanitary throughout the home. (Report continued on LIC809C.)

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

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 07/14/2023 01:41 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: J AND C HOUSE OF LOVE	FACILITY NUMBER: 198602890
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in which LPA observed cleaning supplies and sharps unlocked in the kitchen, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/17/2023
	Plan of Correction
1 2 3 4	The facility will ensure all cleaning supplies and sharps are secured in the kitchen and provide staff training by POC due date.

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.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: J AND C HOUSE OF LOVE	FACILITY NUMBER: 198602890
	VISIT DATE: 07/14/2023

NARRATIVE

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The outdoor grounds were toured and inspected, and the patio was well maintained with a shaded seating area accessible for client use. The garage contained a working washer and dryer, with cabinetry that contained bottled water, toiletries, personal care supplies, and toxins and cleaning agents stored locked and inaccessible to the clients.

The following Deficiencies were cited on the LIC809D under Title 22 California Code of Regulations Division 6, Chapter 1 & 6. Exit interview conducted with Chante Smith, Administrator, a copy of this report was provided, and Appeal rights given.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

LIC809 (FAS) - (06/04)

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