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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602958
Report Date: 03/15/2023
Date Signed: 03/16/2023 08:59:12 AM

Document Has Been Signed on 03/16/2023 08:59 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:HOME AWAY FROM HOME ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
198602958
ADMINISTRATOR:THOMAS, MARKFACILITY TYPE:
735
ADDRESS:2714 WEST 108TH STREETTELEPHONE:
(323) 474-5236
CITY:INGLEWOODSTATE: CAZIP CODE:
90303
CAPACITY: 3CENSUS: 0DATE:
03/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Mark ThomasTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced required 1- year visit with the primary focus on Infection Control measures and using the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA was properly screened for COVID-19 symptoms and LPA temperature was checked. LPA Bunker met Licensee Mark Thomas and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved mitigation plan report. There are currently zero (0), Westside Regional Center Adult Residential Care Facility (ARF) consumers in placement. The facility's annual fees are current.

The following 11 Domain will be observed and reviewed: Infection Control, Physical Plant & Environmental, Operational Requirements, Staffing, Personnel Records-Training, Client Rights-Information, Client Rights-Incident Reports, Food Service, Health-Related Services, Incidental Medical Services, and Disaster Preparedness "I will be using this tool and methods that have been developed to improve the efficiency and accuracy of the Department of Social Services' facility inspections."

The facility is a single-family home located in a residential neighborhood. It consists of the following: Living room/office, kitchen, dining area, laundry area, 3 bedrooms, 1 1/2 bathrooms, patio shaded area, indoor and outdoor activity area, storage house in the backyard, and a detached garage. See continued LIC809-C on page 2
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE: DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/15/2023
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: HOME AWAY FROM HOME ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198602958
VISIT DATE: 03/15/2023
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Continued LIC809-C page 2

Documents are posted as mandated. Bedrooms contain the furniture mandated, and bathrooms are clean and operational. Personal accommodations were observed for safety, privacy, comfort, and non-skid surface mats. The kitchen was observed for its ability to prepare and serve food. The food service was reviewed for appropriate quantity and proper storage; there was an ample supply of perishable and nonperishable food. The resident’s medications were reviewed for proper storage, documentation, and system implementation. Medications are locked, and records are current. Common areas observed for the ability to safely serve the needs of the residents, including cleanliness, and clear of any potential hazards to the residents. The first aid kit is fully stocked with manual, smoke, and carbon monoxide detectors were in compliance, the hot water temperature was measured at 105 degrees Fahrenheit within the normal limits (105-120F degrees), the fire extinguisher is fully charged, adequate linen supply, the facility telephones are working, resident. The client's bedroom windows have no sliding window lock with thumbscrews, all exit doors were in compliance, the yard was free of debris hazards, and trash cans were covered. Staff was given training on dependent adult and elder abuse reporting.

There were no deficiencies cited.

Exit interview conducted.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023
LIC809 (FAS) - (06/04)
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