198603188-10-7-2021-11-AS-MBRN-C7KU4B-20211007151453

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603188
Report Date: 10/07/2021
Date Signed: 10/07/2021 03:15:16 PM

Document Has Been Signed on 10/07/2021 03:15 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	BRUCE & NELSON RESIDENTIAL FACILITY		FACILITY NUMBER:	198603188
ADMINISTRATOR:	NELSON, KENDRA D		FACILITY TYPE:	735
ADDRESS:	1722 WEST 165TH STREET		TELEPHONE:	(424) 785-5412
CITY:	COMPTON	STATE: CA	ZIP CODE:	90220
CAPACITY: 4		CENSUS: 3	DATE:	10/07/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:29 PM
MET WITH:	Kendra Williams-DSP		TIME COMPLETED:	03:30 PM

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Licensing Program Analyst (LPA) Martessa Brown conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA was met by Kendrea Williams, DSP and the purpose of today’s visit was explained. The facility is licensed to serve 4 developmentally disabled clients (Age 18-59).

There are currently (3) Westside Regional Center clients in placement. All (3) clients are ambulatory. The facility is a single story structure located in a residential neighborhood. It consists of the following: 3 bedrooms, 3 bathrooms, family room/dining room, kitchen, living room, indoor and outdoor activity area, laundry room and an attached garage.

LPA and staff toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, 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 and were clean and operational. The water temperature measured in bathroom #1 109.8 F and #112 F. Bathroom #3 is for staff. A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is perishable and non-perishable food available which is stored properly. Fire extinguisher was charged, smoke detectors and Carbon Monoxide were operable.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations ( Located in common areas and restrooms). LPA observed staff and residents were wearing face coverings, an isolation room and required postings throughout the facility. LPA observed the facility.

LIC 809-C s on the next page.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

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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Document Has Been Signed on 10/07/2021 03:15 PM - It Cannot Be Edited

Created By: Martessa Brown On 10/07/2021 at 01:59 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BRUCE & NELSON RESIDENTIAL FACILITY	FACILITY NUMBER: 198603188
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/07/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80075(c)

Health-Related Services

(c) The isolation room or area specified in Section 80087(d) shall be used where separation from others is required. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. LPA temperature was not check/screen at the initial visit. LPA did not see a sign in sheet or temperature log for staff, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/14/2021
	Plan of Correction
1 2 3 4	Administrator will send an outline on how she will ensure visitors/staff temperatures are recorded and screen by POC due date 10/14/21.

Type B

Section Cited

CCR

80078(a)

Responsibility for Providing Care and Supervision

(a)The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [3] residents did not have their temperature check. LPA did not see a log sheet for residents in care, which poses/posed a potential health, safety or personal rights risk to persons in care
	POC Due Date: 10/14/2021
	Plan of Correction
1 2 3 4	Administrator will ensure all residents temperature are check in the AM/PM and recorded. Administrator will send an outline on how she will maintain residents temperature will be recorded will be check by POC due date 10/7/21.

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:

Janae Hammond

LICENSING EVALUATOR NAME:

Martessa Brown

LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BRUCE & NELSON RESIDENTIAL FACILITY	FACILITY NUMBER: 198603188
	VISIT DATE: 10/07/2021

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LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued a citation.

An exit interview was conducted, and a copy of Report and Appeal Rights provided to Kendrea Williams.

See LIC 809-D is on the next page.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

LIC809 (FAS) - (06/04)

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