198603158-9-8-2023-11-AS-PSCT-CVGSUK-20230908141116

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603158
Report Date: 09/08/2023
Date Signed: 09/08/2023 02:11:22 PM

Document Has Been Signed on 09/08/2023 02:11 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:	ONE CARE ADULT RESIDENTIAL HOME		FACILITY NUMBER:	198603158
ADMINISTRATOR:	SULLIVAN, BRIAN		FACILITY TYPE:	735
ADDRESS:	1330 W MAGNOLIA ST		TELEPHONE:	(310) 926-3109
CITY:	COMPTON	STATE: CA	ZIP CODE:	90220
CAPACITY: 4		CENSUS: 3	DATE:	09/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:26 PM
MET WITH:	Brian Sullivan		TIME COMPLETED:	02:30 PM

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On 09/08/23 at 12:20pm, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Brian Sullivan, Licensee, and the purpose of today’s visit was explained. The facility is licensed to operate for (4) ambulatory, (Developmentally Disabled Adults) ages 18 through 59. Currently, the home has (3) clients. The clients are South Central Los Angeles Regional Center clients. None of the clients have Restricted Health Care Conditions and none utilizes postural supports or protective devices. The facilities’ annual fees are due on 09/17/23 with a balance of $454.00.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: 3 bedrooms, 2 bathrooms, living room/office, dining room & kitchen, shaded area, indoor and outdoor activity area, laundry room and attached garage.

LPA conducted a records review of (3) client records, (5) staff records, (3) clients Personal & Incidental Records and reviewed the facility disaster plan. All client & Staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (3) Client Medication Administration Records and did not observe any discrepancies at the time of visit.

LPA and Mr. Sullivan toured the physical plant at 12:30pm. There are no bodies of water or firearm/ammunition on the premises. All resident rooms were checked. Beds and bedding were in good condition, adequate lighting provided, adequate storage for client personal belongings was observed. Walls and floors were 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 regulations. Toilets and water faucets worked properly. The shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature measured at 113.5F. A comfortable temperature is maintained in the facility.

Report continue on LIC809-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

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: ONE CARE ADULT RESIDENTIAL HOME	FACILITY NUMBER: 198603158
	VISIT DATE: 09/08/2023

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LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is enough perishable and non-perishable food available, which is stored properly. All appliances were in working condition. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked, with a manual. The fire extinguishers were charged and last inspected on 8/12/2023. Smoke/ Carbon Monoxide detectors were operable. The last fire/emergency drill was conducted on 08/01/2023.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents. LPA observed that sanitizing stations were in common areas and restrooms. LPA observed that the facility had the required postings, posted throughout the facility. LPA further observed the facility to have a 60-day supply of Personal Protective Equipment (PPE).

LPA advised the administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing (www.cdss.ca.gov) for Provider Informational Notices (PIN) and for any updates relating to COVID-19 guidance and other related issues.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview was held, and a copy of the Facility Evaluation Report was provided to Brian Sullivan, Licensee.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

LIC809 (FAS) - (06/04)

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