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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603180
Report Date: 09/16/2021
Date Signed: 09/16/2021 05:48:07 PM

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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:RAECHELLE CARE HOMEFACILITY NUMBER:
198603180
ADMINISTRATOR:BERG, TIAFACILITY TYPE:
735
ADDRESS:2215 W 15TH STTELEPHONE:
(323) 656-8266
CITY:LOS ANGELESSTATE: CAZIP CODE:
90006
CAPACITY:30CENSUS: 29DATE:
09/16/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Martin EspinozaTIME COMPLETED:
06:00 PM
NARRATIVE
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On 9/16/2021 at 9 a.m. Licensing Program Analysts (LPAs) , Nina Galarza and Nune Margaryan conducted an unannounced Case Management visit. Purpose of the visit was to address deficiencies observed during an inspection. LPAs met with Med Tech, Martin Espinoza and stated the purpose of the visit. LPAs conducted tour with Martin Espinoza at approximately 10:50 a.m. The facility is currently being renovated on second floor.

During the visit LPAs observed the following deficiencies:
  • LPAs were not screened upon entry
  • Limited COVID informational posting in the front area of the facility, no COVID informational postings throughout facility or in any bathrooms
  • A non-functioning door on side of house that allows entry underneath the house where gardening tools, plumbing pipes and electrical wires are present that cannot be secured at this time
  • Covered concrete materials in back area behind facility
  • Concrete, paint primer and tools at end of hallway by room 18
  • Discarded doors and door way in interior stairway
  • A broken door knob to room 3 that does not allow door to close
  • A hole in door of client bathroom on first floor
  • A light switch in disrepair in client bathroom on first floor
  • A broken screen on window of staff room on first floor
  • A lock on front gate that does not allow exit passage way, used from 9 p.m. to 7 a.m.
  • License is not posted in a prominent, public accessible location inside of facility
  • No Sample menu posted that indicated food served for the day
  • Signal System in disrepair
CONTINUED 809-C
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Nina GalarzaTELEPHONE: 323-981-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
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
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: RAECHELLE CARE HOME
FACILITY NUMBER: 198603180
VISIT DATE: 09/16/2021
NARRATIVE
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Deficiencies cited under California Code of Regulations, refer 809-D

Exit Interview conducted, copy of report and appeal rights provided to Martin Espinoza
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Nina GalarzaTELEPHONE: 323-981-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: RAECHELLE CARE HOME
FACILITY NUMBER: 198603180
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/17/2021
Section Cited

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80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
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LPA observed a non-functioning door on side of house that allows entry underneath the house where gardening tools, plumbing pipes and electrical wires are present that cannot be secured at this time. LPAs were not screened upon entry. LPAs observed limited COVID informational posting in the front area of the facility, no COVID informational postings throughout facility or in any bathrooms. LPA observed covered concrete materials in back area behind facility. LPA observed concrete, paint primer and tools at end of hallway by room 18. LPA observed a broken door knob to room 3 that does not allow door to close. LPA observed a hole in door of client bathroom on first floor. LPA observed a light switch in disrepair in client bathroom on first floor. LPA observed a screen a broken screen of window of staff room on first floor. LPA Signal System in disrepair
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Type A
09/17/2021
Section Cited

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80087 Buildings and Grounds (c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
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LPA observed discarded doors and door way in interior stairway.
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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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Nina GalarzaTELEPHONE: 323-981-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: RAECHELLE CARE HOME
FACILITY NUMBER: 198603180
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/17/2021
Section Cited

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80072 Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
This requirement is not met as evidenced by:
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LPA observed a lock on front gate that does not allow exit passage way, used from 9 p.m. to 7 a.m.
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Type B
09/24/2021
Section Cited

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85009 Posting of License (a) In facilities with a licensed capacity of seven or more, the license shall be posted in a prominent, publicly accessible location in the facility.

This requirement is not met as evidenced by:
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LPA observed license is not posted inside of facility
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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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Nina GalarzaTELEPHONE: 323-981-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2021
LIC809 (FAS) - (06/04)
Page: 4 of 5
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: RAECHELLE CARE HOME
FACILITY NUMBER: 198603180
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/24/2021
Section Cited

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80022 Plan of Operation (b) The plan and related materials shall contain the following: (9) Sample menus and a schedule for one calendar week indicating the time of day that meals and snacks are to be served.

This requirement is not met as evidenced by:

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LPA observed No Sample menu posted that indicated food served for the day
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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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Nina GalarzaTELEPHONE: 323-981-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5