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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603108
Report Date: 07/12/2024
Date Signed: 07/12/2024 11:00:29 AM

Document Has Been Signed on 07/12/2024 11:00 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:CARRIAGE CREST HOMECAREFACILITY NUMBER:
198603108
ADMINISTRATOR/
DIRECTOR:		RODERICK, TOMFACILITY TYPE:
735
ADDRESS:553 E 222ND STTELEPHONE:
(310) 989-8017
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 4CENSUS: 4DATE:
07/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:28 AM
MET WITH:Eboney Jones TIME VISIT/
INSPECTION COMPLETED:
11:09 AM
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On 0712/24, Licensing Program Analysts (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with House Manager Ebony Jones. LPA explained the purpose of today’s visit. The facility is licensed to operate for (4) ambulatory and (2) non-ambulatory adults 18 through 59. Currently, the facility has no hospice client in care. The facility is approved for (1) hospice client. The residents are all Harbor Regional Center consumers.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: (4) residents' rooms, (3) bathrooms, a living area, a dining area, a kitchen, an outside seating area, and a garage used for storage.

LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 108.7 degrees F. A comfortable temperature of 70 F. degrees was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. A fire extinguisher was charged. A review of the Medication Records Administration (MAR) was observed to be maintained in place.

LPA observed First Aid Kit was maintained. A working landline phone was operational. The last fire drill was conducted on 07/10/24. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current Liability Insurance and a Surety Bond on file.
(Evaluation Report continues LIC 809-C)
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2024
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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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: CARRIAGE CREST HOMECARE
FACILITY NUMBER: 198603108
VISIT DATE: 07/12/2024
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During the visit, LPAs observed the facility's infection control practices. LPAs observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPAs observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

An audit of clients #1-#4 (C1-C4) service files and staff #1-#6 (S1-S6) personnel files revealed to be complete. An audit of the resident's P&I is maintained in order and complete. The facility has the current administrator's certification on file for Maria Roderick expiration date 07/30/25 #6003279735 and Tom Roderick expiration date 12/27/25 #7003282735.

No deficiencies during this inspection visit.

An exit interview was conducted with Eboney Jones a copy of the report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2024
LIC809 (FAS) - (06/04)
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