198602996-8-11-2022-11-AS-PSCT-CH7PFB-20220811111628

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602996
Report Date: 08/11/2022
Date Signed: 08/11/2022 11:16:35 AM

Document Has Been Signed on 08/11/2022 11:16 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:	SAR ADULT HOME CARE		FACILITY NUMBER:	198602996
ADMINISTRATOR:	SAR, VASHNA		FACILITY TYPE:	735
ADDRESS:	926 E 163RD ST		TELEPHONE:	(562) 301-6726
CITY:	CARSON	STATE: CA	ZIP CODE:	90746
CAPACITY: 4		CENSUS: 4	DATE:	08/11/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Vashna Sar		TIME COMPLETED:	11:20 AM

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Licensing Program Analyst (LPA) Perry Scott and LPA Ernand Dabuet, made and unannounced inspection to Sar Adult Home Care. The purpose of today’s visit was to conduct the Required Annual inspection, with an emphasis on infection control. During today’s visit, LPAs met with Administrator Vashna Sar and explained the reason for the visit. The facility has a capacity of 4 clients. The facility currently has 4 clients. All clients are between the ages of 18-59.

LPAs toured the facility along with Administrator Vashna Sar. The home consists of 4 client bedrooms, 3 bathrooms, living room, kitchen, dining area, laundry room and an office. All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Walls and floors were clean and in good repair. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation, and both had adequate equipment for physically handicapped clients. Toilets and water faucets worked properly. Showers were free of mold/mildew, adequate lighting, and sufficient toiletries were accessible to clients. Water temperature measured between 105*-120F*.

Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Smoke/ carbon monoxide detectors were working properly. Fire extinguisher was fully charged and operational; toxins and sharps were locked and inaccessible to clients. Medications were locked and inaccessible to clients, first aid kit was checked and in order, including manual. Outside grounds were toured and no bodies of water were observed. Shaded area was accessible to residents. Exits/ Walkways around the home were free of debris and hazards.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022

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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SAR ADULT HOME CARE	FACILITY NUMBER: 198602996
	VISIT DATE: 08/11/2022

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During the visit, LPAs observed the following to be in compliance: the facility's infection control practices; screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms; every staff was wearing a face covering; the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has a Mitigation Plan Report approved by CCLD.

No deficiencies cited. Exit Interview Conducted and a copy of report was given to Administrator Vashna Sar.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022

LIC809 (FAS) - (06/04)

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