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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602984
Report Date: 03/14/2022
Date Signed: 03/15/2022 04:48:14 PM

Document Has Been Signed on 03/15/2022 04:48 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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:ALBERTSON RESIDENTIAL CAREFACILITY NUMBER:
198602984
ADMINISTRATOR:MARTIN, LATIESHAFACILITY TYPE:
735
ADDRESS:13903 S ALBERTSON AVETELEPHONE:
(310) 438-3526
CITY:COMPTONSTATE: CAZIP CODE:
90222
CAPACITY: 4CENSUS: 3DATE:
03/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Lateishia MartinTIME COMPLETED:
03:52 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ulysses Coronel conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA was met by Lateishia Martin, administrator and the purpose of today’s visit was explained. The facility is licensed to serve 4 developmentally disabled clients 18 thru 59 years; ambulatory only.

There are currently 3 South Central Los Angeles Regional Center clients in placement. The facility is a single-story structure located in a residential neighborhood. The home consists of 3 Bedrooms, 1 Bathroom, Living Room, Kitchen and Dining area.

LPA and administrator toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms was found to be within Title 22 regulations and was clean and operational. A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. Fire extinguisher was charged, smoke detectors and Carbon Monoxide were operable.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations located in common areas and restroom. LPA observed staff wearing face coverings and required postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2022
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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ALBERTSON RESIDENTIAL CARE
FACILITY NUMBER: 198602984
VISIT DATE: 03/14/2022
NARRATIVE
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LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

During today’s visit The water temperature measured at 137.7 F. and the door leading to the bathroom is being obstructed by the clients bed in bedroom 1. Title 22, Division 6 and Chapter 1 is being cited on attached LIC809D form.

Plans of corrections were developed and exit interview held. A copy of the report and appeals rights were provided to Lateishia Martin, Administrator.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/15/2022 04:48 PM - It Cannot Be Edited


Created By: Ulysses Coronel On 03/14/2022 at 02:51 PM
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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ALBERTSON RESIDENTIAL CARE
FACILITY NUMBER: 198602984

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above the hot water temperature on the bathroom sink tested at 137.7 F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/15/2022
Plan of Correction
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The administrator agreed to have the water temperature turned down to not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) during todays visit. The administrator also agreed to create a plan to ensure that the hot water temperature not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). Proof of correction will be submitted by 03/07/2022 via email to ulysses.coronel@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:Janae Hammond
LICENSING EVALUATOR NAME:Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2022


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 03/15/2022 04:48 PM - It Cannot Be Edited


Created By: Ulysses Coronel On 03/14/2022 at 02:51 PM
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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ALBERTSON RESIDENTIAL CARE
FACILITY NUMBER: 198602984

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above the door that leads into the bathroom is being blocked by the clients bed in bedroom 1, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2022
Plan of Correction
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The administrator agreed to create a plan to ensure that all outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard will be kept free of obstruction. Proof of correction will be submitted by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Janae Hammond
LICENSING EVALUATOR NAME:Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2022


LIC809 (FAS) - (06/04)
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