198603082-1-23-2023-11-AS-PBUR-CNCSFY-20230123125106

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603082
Report Date: 01/19/2023
Date Signed: 01/23/2023 12:51:10 PM

Document Has Been Signed on 01/23/2023 12:51 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	FAMILY HANDS ADULT CARE FACILITY III		FACILITY NUMBER:	198603082
ADMINISTRATOR:	TATE, JOHN & TINA SCRUGGS		FACILITY TYPE:	735
ADDRESS:	11636 ST ANDREWS PL		TELEPHONE:	(323) 240-5833
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90047
CAPACITY: 4		CENSUS: 3	DATE:	01/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	John Tate		TIME COMPLETED:	03:51 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	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 temperature was checked. LPA Bunker met Licensee John Tate and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved mitigation plan report. There are currently three (3), Westside Regional Center (WRC) Adult Residential Care Facility (ARF) consumers in placement. The facility's annual fees are current. The following Domain will be observed and reviewed: Infection Control Practices "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 story single-family home located in a residential neighborhood. Licensee John Tate and LPA Bunker toured the facility which consisted of the following: Living room, dining area, kitchen, 3 bedrooms, 2 bathrooms, bonus room, laundry area in the kitchen, shaded area, and indoor/outdoor activity areas. The front and back yard landscape is in good condition at the time of the visit. See continued LIC809-C on page 2

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023

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: FAMILY HANDS ADULT CARE FACILITY III	FACILITY NUMBER: 198603082
	VISIT DATE: 01/19/2023

NARRATIVE

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Continued LIC809-C page 2

Documents are posted as mandated. The following Title 22 regulated areas were audited and found to be in compliance: Bedrooms contain the required furniture, and bathrooms are clean and operational, with non-skid surface mats. Personal accommodations were observed for safety, privacy, and comfort. 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 in the dining area cabinets, and records are current. Common areas were observed for the ability to safely serve the needs of the residents, including cleanliness, and clearness 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 measured at 107 degrees Fahrenheit within the normal limits (105-120F degrees), the fire extinguisher is fully charged, there are adequate lights and linen supply, and the facility telephones are working. A fire/emergency drill was conducted on November 18, 2022. There are no firearms on the premises, The resident's bedroom windows have no sliding window lock with thumbscrews, all exit doors were in compliance, covered trash cans, and no bodies of water were present. Hazardous items are inaccessible to clients, the yard is free of debris and hazards.

Mr. stated 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: 01/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023

LIC809 (FAS) - (06/04)

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