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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602970
Report Date: 05/17/2024
Date Signed: 05/17/2024 03:39:12 PM


Document Has Been Signed on 05/17/2024 03:39 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:SOMERSET HOMECAREFACILITY NUMBER:
198602970
ADMINISTRATOR:FACILITY TYPE:
740
ADDRESS:1309 E SOMERSET PLTELEPHONE:
5626120436
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY:6CENSUS: 5DATE:
05/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:47 AM
MET WITH:Jovan Iglesias, LicenseeTIME COMPLETED:
04:03 PM
NARRATIVE
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On 05/17/24 Licensing Program Analyst (LPA) Mario Leon conducted a required annual inspection using the CARE Inspection Tool. LPA was greeted by Licensee Jovan Iglesias (S1) and the purpose of the visit was explained. As a part of the inspection, LPA reviewed all 5 client service records, personnel records and medications. LPA inspected the inside/outside facility grounds along with S1.

This home consists of 4 client bedrooms and 3 client bathrooms, living room, kitchen, dining area, activity room, laundry area and patio. There were 5 residents present during the inspection. There were adequate perishable and non-perishable food supply were kept at the home and fully stocked in kitchen cabinets. LPA reviewed facilities' 5-year fire sprinkler system report, noting all fire equipment are working properly. During the inspection, LPA observed the following client rooms: mattresses and box springs in working condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. LPA observed additional stocked bedding and towels in closets. All bathroom fixtures are in working condition, yet located cleaning agents under bathroom 1. Cleaning agents were immediately relocated while LPA was on-site, see LIC9102A. Water temperature properly measured at 108.0 degrees F in the kitchen. Showers were free of mold/mildew, adequate lighting, and sufficient toiletries accessible to clients. LPA observed sufficient bedding, linens, and walls and floors were clean and in good repair.


All 3 staff present have obtained criminal clearance, though not associated to the facility. See LIC809-D.

During today's visit, there has been one (1) technical violation, 1 technical advisory, and 1 deficiency cited.
An exit interview was held with Jovan Iglesias (S1) and a copy of this report, technical violation, technical advisory and deficiency, along with appeal rights, have been provided.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2024
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 05/17/2024 03:39 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245


FACILITY NAME: SOMERSET HOMECARE
FACILITY NUMBER: 198602970

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record reviews, the licensee did not comply with the section cited above in having two (2) staff and one (1) volunteer being not associated to the above menitoned facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2024
Plan of Correction
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Licensee (S1) and LPA have agreed that Licensee will obtain access and update roster for Somerset, through the Guardian system on or prior to the POC due date which is 05/24/24. S1 will inform LPA via email at Mario.Leon@DSS.CA.GOV
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: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2024
LIC809 (FAS) - (06/04)
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