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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603031
Report Date: 08/30/2021
Date Signed: 08/31/2021 08:14:45 AM

Document Has Been Signed on 08/31/2021 08:14 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:ANZAC RESIDENTIAL CAREFACILITY NUMBER:
198603031
ADMINISTRATOR:ROBINSON, ANDREAFACILITY TYPE:
735
ADDRESS:12323 S ANZAC AVETELEPHONE:
(310) 901-5428
CITY:COMPTONSTATE: CAZIP CODE:
90222
CAPACITY: 6CENSUS: 0DATE:
08/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Andrea RobinsonTIME COMPLETED:
11:56 AM
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 Andrea Robinson, Administrator and the purpose of today’s visit was explained. The facility is licensed to serve clients age range 18 through 59. approved to serve 6 ambulatory clients.

There are currently zero (0) South Centra Los Angeles Regional Center clients in placement. The facility is a single story structure located in a residential neighborhood. It consists of the following: a living room, kitchen, dining room, 4 bedrooms (1 staff), 2 bathrooms(1 for staff), laundry area, garage, front and back yard.

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, storage for client personal belongings was observed. Walls and floors were in good repair. LPA did not observe night lamps in all client bedrooms. LPA did not observe night lights in the bedroom hallway leading from bedroom# 3 to the bathroom. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 81.1F. 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 are enough perishable and non-perishable food available which is stored properly. Fire extinguisher was charged, smoke detectors and Carbon Monoxide were operable. LPA did not observe a shaded area comfortably furnished for outdoor use.

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 restrooms). LPA observed staff were wearing face coverings, an isolation room 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: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2021
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 5
Document Has Been Signed on 08/31/2021 08:14 AM - It Cannot Be Edited


Created By: Ulysses Coronel On 08/30/2021 at 10:28 AM
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: ANZAC RESIDENTIAL CARE
FACILITY NUMBER: 198603031

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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 , during todays visit, the water temperature measured 81.1F which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2021
Plan of Correction
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The administrator agreed to have the plumber service the water boiler to automatically regulate the hot water tenmperature between 105 and 120 degrees fahrenheit. proof of correction will be submitted by POC due date.
Type B
Section Cited
CCR
85088(c)(2)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (2) Bedroom furniture including, in addition to (c)(1) above, for each client, a chair, a night stand, and a lamp or lights necessary for reading.

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 during todays visit LPA did not observe night lamps in all client bedrooms, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2021
Plan of Correction
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The adminstrator agreed to provide all client bedrooms with nightlamps proof of corrections will be submitted to LPA by POC due date.
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: 08/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2021


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 08/31/2021 08:14 AM - It Cannot Be Edited


Created By: Ulysses Coronel On 08/30/2021 at 10:28 AM
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: ANZAC RESIDENTIAL CARE
FACILITY NUMBER: 198603031

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Emergency lighting, which shall include at a minimum working flashlights or other battery-powered lighting, shall be maintained and readily available in areas accessible to clients and staff. (2) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

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 during todays visit LPA did not observe night lights in the bedroom hallway leading from bedroom# 3 to the bathroom, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2021
Plan of Correction
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The administrator agreed to have night lights installed in the bedroom hallway. Proof of correction will be submitted to LPA by POC due date.
Type B
Section Cited
CCR
85087.2(b)
Outdoor Activity Space
(b) The outdoor activity area shall provide a shaded area, and shall be comfortable, and furnished for outdoor use.

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 in during todays visit LPA did not observe a shaded area comfortably furnished for outdoor use, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2021
Plan of Correction
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The administrator agreed to furnish a shaded area for outdoor use, proof of correction will be submitted to LPA by POC due date.
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: 08/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2021


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: ANZAC RESIDENTIAL CARE
FACILITY NUMBER: 198603031
VISIT DATE: 08/30/2021
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 there were deficiencies observed. Title 22 regulations are being cited please see LIC809D.

Exit interview held. A copy of the report and appeal rights were provided to Andrea Robinson.

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

DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021
LIC809 (FAS) - (06/04)
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