198602892-1-23-2023-28-AS-ALOZ-CNCUNV-20230123144432

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602892
Report Date: 01/23/2023
Date Signed: 01/23/2023 02:44:40 PM

Document Has Been Signed on 01/23/2023 02:44 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	JEFFERSON PARK ELDERLY BOARD AND CARE		FACILITY NUMBER:	198602892
ADMINISTRATOR:	CHARLOT, ANITA		FACILITY TYPE:	740
ADDRESS:	1190 WEST 36TH STREET		TELEPHONE:	(323) 731-5713
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90007
CAPACITY:	6	CENSUS: 0	DATE:	01/23/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:01 PM
MET WITH:	Anita Charlot, Licensee		TIME COMPLETED:	02:59 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

Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced annual inspection. LPA met with administrator Anita Charlot and explained the reason of the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant. Facility currently has not submitted the mitigation plan yet.

Currently the facility has no resident residing here. This facility is located in a residential area and is a two story home. The home consists of three (3) resident bedrooms, one (1) staff bedrooms, two (2) bathrooms, kitchen, dining room, den, detached garage, a basement used for water heater and furniture storage and backyard area. The facility is required to have auditory devices on exit doors for dementia residents. The auditory devices were not operating at the time of the visit. All bedrooms do not have the required linen and proper furniture due to flooding and is in storage.. All toilets, hand washing and bath tub/shower were not inspected due to recent flooding at home and no access during visit.. No sharp knives and cleaning supplies were at facility . LPA inspected the smoke detector and carbon monoxide and they are all interconnected, operable and in compliance. The hot water was not measured during the visit due to home being under construction due to flooding. LPA did not observe an appropriate food supply of two (2) days perishables and one week (7 days) non-perishables since there are no residents residing at facility. LPA entered through the front door and observed the dining room to be under repair due to flood. The walls only had skeleton 2x4 frame visible and the adjacent kitchen had part of the countertop on the ground near the back door. There is a gapping hole in the ceiling in the dinning room about 2 feet in diameter that goes to the upstairs section of the home. There are many objects/furniture in the back yard that were taken out of the home due to the flood. There is no stove, table, chairs, washing machine, dryer, dishes or cups at the time of visit. All of the PPE was taken to storage so there is none at the facility at the time of visit.

Deficiencies cited (please see 809D for details)

Exit interview conducted and copy of report and appeal rights provided to Licensee Anita Charlot

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

Document Has Been Signed on 01/23/2023 02:44 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: JEFFERSON PARK ELDERLY BOARD AND CARE	FACILITY NUMBER: 198602892
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87035(a)

Licensee will provide LPA with permit by POC date. 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. Home is under repair due to flood and Licencee failed to provided permit which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/06/2023
	Plan of Correction
1 2 3 4	Licensee will provide LPA with permit by POC 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) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2