198603257-3-12-2024-28-AS-EZAA-D3ASA4-20240312134145

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603257
Report Date: 03/07/2024
Date Signed: 03/12/2024 01:42:21 PM

Document Has Been Signed on 03/12/2024 01:42 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:	SHAWNTA FAMILY HOME		FACILITY NUMBER:	198603257
ADMINISTRATOR:	PLAYER, SHAWNTA		FACILITY TYPE:	735
ADDRESS:	152 WEST 88TH PLACE		TELEPHONE:	(562) 618-4057
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90003
CAPACITY: 4		CENSUS: 0	DATE:	03/07/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:16 PM
MET WITH:	Shawnta Player		TIME COMPLETED:	01:56 PM

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Licensing Program Analysts (LPAs) Erik Zaragoza and Daniel Konishi conducted an unannounced Required 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to Shawnta Player, Administrator of the facility, and was granted entrance. There are no clients that currently reside in the home.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention.

Infection Control:

· Infection control practices and Personal Protective Equipment (PPEs) were observed. LPA observed that the facility had a completed infection control plan.

· Administrator has an infection control plan in place.

Physical Plant/Environment Safety:

· The facility is a single-story home located in a residential neighborhood that is licensed for a capacity of four (4) clients between the ages of 18 – 59, four (4) of which may be non-ambulatory. It consists of three (3) client bedrooms, a kitchen, a dining room, living room, a client bathroom that had a hot water temperature reading measured at 104.1 Degrees F, a laundry room, and an outdoor patio area in the backyard that will have a shaded area along with a storage area, office area, and shed. Knives are kept locked in a storage area of the facility, and the chemicals and cleaning solutions will be kept locked in a cabinet in the kitchen.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

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: SHAWNTA FAMILY HOME	FACILITY NUMBER: 198603257
	VISIT DATE: 03/07/2024

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·The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Fire alarm system is operational. The facility has one (1) fully charged fire extinguishers that are kept in the facility. Cleaning supplies and toxic substances are kept locked and inaccessible to clients.
· Water temperature readings measured below the required 105 - 120 degrees Fahrenheit range at 104.1 Degrees F. Administrator was advised that the range will need to be at least 105 Degrees F when clients are present in the facility.
Operational Requirements:
· The Program Design was reviewed.

· Fire clearance was approved by LA County Fire Department for four (4) non-ambulatory clients between the ages of 18 – 59.

· Care and supervision to meet the clients’ needs was observed.
Staffing:

· A total of four (4) full-time staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

· Administrator’s certificate expires on 6/9/2025.

· No staff files were reviewed for criminal background clearance and training, as no clients are present.
· No personnel records are available that have health/Tuberculosis (TB) screenings, certifications, and 1st Aid/CPR training.
Client Rights/Information:

· Physician orders were reviewed in client files.

Client Records/Incident Reports:

· There were no client files available for review containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, nutritional assessments, medication records, and Personal and Incidental (P & I) money were reviewed.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024

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: SHAWNTA FAMILY HOME	FACILITY NUMBER: 198603257
	VISIT DATE: 03/07/2024

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Food Service:

· The kitchen was inspected and the food preparation area, and storage areas were observed to be clean and sanitary. A seven (7) day supply of non-perishable food and two (2) day supply of perishable foods were observed in the kitchen.

· No restricted Health Care plan required for the clients in the facility.

Health Related Services:

· Clients are assisted with self-administration of prescription and non-prescription medications.

· There were no centrally stored client medication records that were available for review. Centrally stored medications are kept in a safe and locked place not accessible to clients in care. Medications are given according to Physician directions.
Incidental Medical and Dental:

· No client files were available to check if they have a Needs and Services Plan, and COVID-19 vaccination cards on file.

· There were no staff training was on file.
Disaster Preparedness, and Emergency Intervention:

· An Emergency Disaster Plan LIC 610D is kept in the facility.

Emergency Intervention:

· No manual restraints or seclusion are used with clients in care.

Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies were observed during the visit. Exit interview held and a copy of the report was provided.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024

LIC809 (FAS) - (06/04)

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