198603311-5-14-2024-28-AS-THEA-D59VRV-20240514164035

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603311
Report Date: 05/14/2024
Date Signed: 05/14/2024 04:41:20 PM

Document Has Been Signed on 05/14/2024 04:41 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:	NURTURE AT ADWEN		FACILITY NUMBER:	198603311
ADMINISTRATOR/ DIRECTOR:	TORRES, PRINCESS W.		FACILITY TYPE:	735
ADDRESS:	7612 ADWEN STREET		TELEPHONE:	(424) 362-6566
CITY:	DOWNEY	STATE: CA	ZIP CODE:	90241
CAPACITY: 6		CENSUS: 4	DATE:	05/14/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:26 PM
MET WITH:	Elsa Bandong - Caregiver		TIME VISIT/ INSPECTION COMPLETED:	04:40 PM

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Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Elsa Bandong (caregiver) who allowed entrance to the facility and moments later Derry Sandajan (House Manager) arrived to assist with the visit. The facility is licensed to serve 6 Ambulatory only clients ages 18 to 59 years old. There are currently 4 Ambulatory clients serviced through South Central Los Angeles Regional Center at the facility.

The facility is a single-story home located in a residential area in Downey, CA. A tour of the facility includes: dining area, office area, kitchen, living room, 3 client bedrooms (one shared room), 2 bathrooms (1 client-1 staff), attached garage, front yard, backyard, and a locked toolshed.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan posted by the entrance.

Physical Plant & Environment Safety: Clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. Bathrooms are clean and operational. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available. The hot water temperature was tested in client bathroom and measured within the required range of 105-120 degrees. All storage areas for cleaning solutions, toxins, knives, and hazardous items are in a secured cabinet and inaccessible to clients. Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguisher was observed in the kitchen area and is fully charged.

(Continued on LIC809-C)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024

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: NURTURE AT ADWEN	FACILITY NUMBER: 198603311
	VISIT DATE: 05/14/2024

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Operational Requirements: Staff have proper training to meet the needs of the clients in care. Facility has an activity area furnished for outdoor use. Last fire/earthquake drill was conducted on 2/26/24.
Staffing: There appears to be sufficient staffing at all times in the facility. Administrator Princess Torres certificate expires on 6/8/2024.
Personnel Records-Training: Staff has criminal record clearance and current first aid and CPR. Staff files are maintained at the facility stored electronically with a secured password setting. Staff have current CPR/First-Aid/CPI training and sufficient on-going training. LPA reviewed 4 staff files with no issues observed
Client Rights-Information: Residents personal rights poster is posted in the dining room.
Client Records-Incident Reports: Client files are kept locked in a cabinet in office area and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. LPA reviewed 4 client files today with no issues observed.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Service: Staff designated to administer medication has the proper annual training on file. Medication is properly labeled and are centrally stored in a locked cabinet and are in their original containers. During the visit today, LPA reviewed all 4 clients’ medication no issues were observed.
Incidental Medical & Dental: All medications for clients are kept locked and inaccessible to other clients.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites.
Emergency Intervention: Residents at this facility do not have restraints nor do they require the use de-escalation techniques, however, staff maintain valid CPI certificates.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during todays visit.

Exit interview held and a copy of the report Adrian Torres.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024

LIC809 (FAS) - (06/04)

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