<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603529
Report Date: 05/31/2024
Date Signed: 05/31/2024 02:23:51 PM


Document Has Been Signed on 05/31/2024 02:23 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:MT. SINAI RESIDENTIALFACILITY NUMBER:
198603529
ADMINISTRATOR:JEFFERSON, JENEROFACILITY TYPE:
735
ADDRESS:1642 6TH AVETELEPHONE:
3105316049
CITY:LOS ANGELESSTATE: CAZIP CODE:
90019
CAPACITY:6CENSUS: 6DATE:
05/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Katheryn JeffersonTIME COMPLETED:
02:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Alma Gonzalez conducted the required annual inspection. LPA met with Lead Staff Katheryn Jefferson and discussed the purpose of today’s visit.

The facility is licensed to serve six (6) developmentally disabled clients (age 18-59) and is approved for five (5) ambulatory and one (1) non-ambulatory. Currently, there are six (6) clients in placement, there are no clients who have a restricted health care condition. All clients residing at this facility receive case management services provided by Frank D Lanterman Regional Center.

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

Infection Control: Facility has an Infection Control Plan in place.

Physical Plant & Environment Safety: The home is located in a residential area and consists of a Living room, kitchen, dining room, family room, six bedrooms, 2 bathrooms, 1 of the 6 bedrooms is designated as a staff bedroom, outside covered area with a detached two garage/storage. All client rooms were inspected and LPA observed client beds and the bedding for each bed were in good condition, adequate lighting provided, storage for client personal belongings was observed for each client. Walls and floors were in good repair. Bathrooms are clean and operational and were observed to be within Title 22 regulations. Toilets and water faucets worked properly. Showers were free of mold/mildew, had adequate lighting, and there are sufficient toiletries that are accessible to clients. Water temperature properly measured at 120 F*. Facility temperature was comfortable and cool. LPA observed the facility to be clean and appropriately furnished with clear passageways inside and outside. Medications are stored, locked and inaccessible to clients. Hazardous toxins and/or items are inaccessible to clients, fire extinguisher is fully charged. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards.

Refer to LIC 809C for the continuation of this report
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
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)
Page: 1 of 2


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: MT. SINAI RESIDENTIAL
FACILITY NUMBER: 198603529
VISIT DATE: 05/31/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Operational Requirements: Staff are adhering to operational requirements. Fire Drills are conducted quarterly, the last fire drill was conducted on 5/09/24. Emergency Disaster/ Earthquake Drills are conducted quarterly and the last one was conducted on 5/09/24. Facility Administrator is adhering to operational requirements.

Staffing: There is sufficient staffing at the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Administrator certificate is current and expires on 03/26/26.

Personnel Records-Training: LPA reviewed staff files for Staff 1 (S1) through Staff 3 (S3). Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file.

Client Rights-Information: Client rights are posted and were also observed in client files.

Client Records-Incident Reports: LPA reviewed Client files for Client 1 (C1) through Client 6 (C6). Client files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Weight Record, Functional Capabilities Assessment, Consent For Medical Treatment, House Rules, Individual Program Plan, and Client Rights were observed.

Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. Cleaning supplies are kept away from the food preparation areas. The kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services: The medications are centrally stored and locked. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubble packed and delivered monthly.

Incidental Medical Services: Per Administrator, there are no clients with a restrictive health plan, no clients utilizing postural supports nor clients with prohibited health conditions.

Disaster Preparedness: The facility has an Emergency Disaster Plan (LIC610D/9 pages) in place.

No deficiencies noted. Exit interview and a copy of this report was provided to Lead Staff Katheryn Jefferson.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2