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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603115
Report Date: 01/08/2024
Date Signed: 01/08/2024 01:18:34 PM

Document Has Been Signed on 01/08/2024 01:18 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SEIDE'S FAMILY AFFAIRFACILITY NUMBER:
198603115
ADMINISTRATOR:KHABERR, NIJIHFACILITY TYPE:
735
ADDRESS:11046 LEIBACHER AVETELEPHONE:
(562) 202-4477
CITY:DOWNEYSTATE: CAZIP CODE:
90241
CAPACITY: 4CENSUS: 3DATE:
01/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Nijih Khabeer - Licensee/AdministratorTIME COMPLETED:
01:40 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required-1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Christine Ogbonda, Direct Support Professional I & II (DSP I & II) and explained the purpose of the visit. Licensee/Administrator Nijih Khabeer arrived at 11:30am and assisted LPA with the inspection. The facility is licensed to care for (4) Developmentally Disabled Adults, (4) ambulatory, ages 18 through 59. All clients residing at this Specialized facility receive case management services provided by South Central LA Regional Center. The facility is a level 4I. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained. The staff stated that they use disposable gloves to clean and disinfect the high touched surfaces in the common areas. The facility has submitted a COVID-19 Mitigation Plan and the Infection Control Plan. Bathrooms have hand washing signs and hand soap. Paper towels are provided to clients on a per use basis, but not kept in the bathrooms for safety reasons. Staff are adhering to infection control requirements.
Physical Plant/Environment Safety: The facility is a single storey home located in a residential neighborhood, contains a total of (3) client bedrooms, (2) bathrooms, a living room, den used as activity area and office area, kitchen, dining area, backyard with shaded area, and detached garage. Currently, there are three (3) clients living in the facility. The interior and exterior physical plant was inspected. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, chair and sufficient closet space. Bathrooms have non-skid materials and contained hygiene supplies including liquid soap, and toilet paper. There is a fire place in the den that is covered and inaccessible to clients. Exit doors are free of any obstruction and there are no pools or large bodies of water. Backyard was inspected and has a shaded area and sitting area. Laundry area is in the kitchen. There are cameras without audio in the front/back yards and common areas inside the home. There is (1) fire extinguisher mounted on the wall in the kitchen which is operable and was serviced on 12/07/2023. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Readings were 113.3 deg. F in bathroom #1 and 110.1 deg. F in bathroom #2.
Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. A fire clearance is in place. Liability Insurance policy in the amount of $1,000,000.00 each occurrence and $3,000,000.00 in the total annual aggregate is valid and expires on 07/27/2024. Surety Bond in the amount of $1000 is in effect. Last Fire Drill was conducted on 07/27/2023. Administrator agreed to conduct a fire/emergency drill no later than Fri., 01/12/2024 and will start conducting the training on a quarterly basis as required by CCL.
*****REPORT CONTINUED ON LIC809-C*****
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2024
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SEIDE'S FAMILY AFFAIR
FACILITY NUMBER: 198603115
VISIT DATE: 01/08/2024
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Staffing: A total of six (6) staff members including the Administrator provide care and supervision to the clients. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility.
Personnel Records/Staff Training: Reviewed files for three (3) staff. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Administrator certificate has expired on 11/31/2023. Proof of renewal was presented to LPA which showed that it was sent in October 2023. Administrator has a valid HIV/AIDS training proof at the time of visit.
Client Rights-Information: Client personal rights are posted. Per Administrator, facility provides internet services to all clients and have access to the facility phone. Administrator stated that (1) client has his own personal cell phone and none of the clients have their own tablet/IPad. LPA interviewed (1) client as the other (2) clients were out in the community during the visit.
Food Service: There are sufficient food supplies of 2-day perishable and 7-day non-perishable items. The food is properly stored in the refrigerator (clean and well maintained). Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly. There is (1) client who is allergic to nuts and shrimp and special diet is provided.
Client Records-Incident Reports: LPA reviewed Client files for C1 through C3. Client files are maintained at the facility. Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Individual Program Plan (IPP), Behavioral Reports, Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights observed.
Health Related Services: The medications are centrally stored and in their original containers. Medications were reviewed for C1-C3 to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubbled packed.
Incidental Medical Services: None of the clients at this home has a restricted health condition.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan. Emergency Intervention: Not-Applicable.

Deficiency cited, exit interview, appeals rights and a copy of this report was provided to the Licensee/Administrator, Nijih Khabeer.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/08/2024 01:18 PM - It Cannot Be Edited


Created By: Bennette Pena On 01/08/2024 at 01:03 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SEIDE'S FAMILY AFFAIR
FACILITY NUMBER: 198603115

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review the licensee did not comply with the section cited above in that LPA observed that the last fire drill was ocnducted on 07/27/2023 which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 01/12/2024
Plan of Correction
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Licensee/Adminisrator agreed to conduct the fire/emergency training no later than Fri., 01/12/2024 and will submit the in-service training signed by staff to CCL/LPA on or before the POC due date.
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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 01/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2024


LIC809 (FAS) - (06/04)
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