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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603257
Report Date: 03/07/2022
Date Signed: 03/07/2022 01:23:01 PM

Document Has Been Signed on 03/07/2022 01:23 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SHAWNTA FAMILY HOMEFACILITY NUMBER:
198603257
ADMINISTRATOR:PLAYER, SHAWNTAFACILITY TYPE:
735
ADDRESS:152 WEST 88TH PLACETELEPHONE:
(562) 618-4057
CITY:LOS ANGELESSTATE: CAZIP CODE:
90003
CAPACITY: 4CENSUS: 0DATE:
03/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:04 AM
MET WITH:Rochelle Woods, Sister of Licensee and Shawnta Player, Licencee via Phone TIME COMPLETED:
01:28 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Required- 1-year visit focusing on COVID-19 Infection Control Practices. LPA was greeted by Rochelle Woods, Sister of licensee and Administrator/Licensee Shawnta Player was on speaker phone during inspection. LPA explained the purpose of the visit. Administrator certificate expires 6/19/2023 Last fire drill was never conducted due to no residents residing at home at time of visit.
Structure:
The Facility is a single storey building in a residential area with 3 resident bedrooms and 1 full bathroom, there’s 1 dining room, a kitchen, a laundry room, and a family room. There is a large back year area on the back premises with tables, chairs and shade that is stored and will be put out when first resident is admitted. All the resident’s bedrooms are spacious and will easily accommodate the resident's furnishings. The passageway and walkways are free of hazard and free from obstruction.
The following were observed/inspected:
· NO COVID-19 signs are posted at the entrance. Visitors are not screened in the main entrance and a log is not kept.
· Water temperature measured 122.1 degrees F In the kitchen sink which is not between 105/120 degress F
· Infection control signs and other COVID-19 signs are NOT posted throughout the facility in the bathrooms, kitchen, and hallway to promote hand washing, cough/sneeze etiquette, and physical distancing.
· Facility does have one designated isolation room.
· 3 client rooms, common areas, bathrooms, and outdoor physical plant was inspected.
· Three client rooms were not equipped with alcohol-based hand sanitizer.
· ZERO centrally stored client medication records were reviewed.
· Staff responsible for direct care and supervision were NOT observed wearing masks.
· Sufficient supply of non-perishable foods for 7 days was not observed. Facility has no residents.
· A posted Emergency Disaster Plan was NOT observed posted at facility.
· NO PPE's were observed.
· Staff and resident files were not reviewed during today's visit.
· Deficiencies were observed during today’s visit. (see 809D)
· Exit interview was conducted with Sister of Licensee and report read via phone to Licensee Shawnta Player. A copy of the report was provided.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2022
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 03/07/2022 01:23 PM - It Cannot Be Edited


Created By: Alberto Lopez On 03/07/2022 at 12:58 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: SHAWNTA FAMILY HOME
FACILITY NUMBER: 198603257

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Water in kitchen sink measured 122.1 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2022
Plan of Correction
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Adminstrator will adjust temperture and send photos to LPA of temperture readings for 3 days.
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:Christine Yee
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2022


LIC809 (FAS) - (06/04)
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