198603537-5-23-2023-28-AS-EZAA-CS4STT-20230523141004

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603537
Report Date: 05/23/2023
Date Signed: 05/23/2023 02:10:26 PM

Document Has Been Signed on 05/23/2023 02:10 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:	A PLACE TO HEAL		FACILITY NUMBER:	198603537
ADMINISTRATOR:	HIGGINBOTHAM, LAKECIA		FACILITY TYPE:	772
ADDRESS:	137 E 104TH STREET		TELEPHONE:	(323) 202-8432
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90003
CAPACITY: 6		CENSUS: 0	DATE:	05/23/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:42 PM
MET WITH:	Christina Baraza - Secretary		TIME COMPLETED:	02:23 PM

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Licensing Program Analyst (LPA) Erik Zaragoza 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 Secretary Christina Baraza, and Licensee/Administrator Lakecia Higginbotham arrived shortly afterwards. There are no clients who are currently living in the home. The administrator is attempting to obtain clients who are Medi-Cal recipients and is actively attempting to obtain clients.

The following 11 (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.

Infection Control:

· Infection control practices and Personal Protective Equipment (PPEs) were observed. The Facility administrator Lakecia Higginbotham advised that she will be emailing LPA her infection control plan within 7 days.

Physical Plant/Environment Safety:

· The facility is a two-story home located in a residential neighborhood that is licensed for a capacity of six (6) ambulatory clients. It consists of 3 shared client bedrooms, an office for staff, a living room, dining room, a kitchen, three (3) shared client bathrooms of which the first restroom located on the first floor R#1 measured at 115.5 degrees, the second restroom on the second floor next to the laundry area R#2 Measured 113.3 degrees F, and the third restroom connected with the upstairs activity room R#3 measured 106.7 degrees F, a front yard area, and an attached garage in the front yard.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

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: A PLACE TO HEAL	FACILITY NUMBER: 198603537
	VISIT DATE: 05/23/2023

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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. Smoke and carbon monoxide detectors are operational. The facility has three (3) fully charged fire extinguishers, one is kept in the kitchen, another kept in the dining room area, and the third is located upstairs in the main area of the house. Cleaning supplies and toxic substances are inaccessible to clients.
· Water temperature readings measured between the required 105 - 120 degrees Fahrenheit.
Operational Requirements:
· The Program Design was reviewed.

· Fire clearance was approved by LA County Fire Department for six (6) ambulatory clients.

· There are no clients who live in the facility and therefore no supervision was needed for anyone at this time.
Staffing:

· Administrator only had her staff file in the facility records because she currently does not have any clients and therefore does not have any employees currently.

Personnel Records/Staff Training:

· Administrator certificate is valid through 12/12/2024.

· LPA reviewed one (1) staff file for criminal background clearance and training.
· LPA reviewed one (1) staff file for health/TB screenings, CPI training, certifications, and 1st Aid/CPR training.
Client Rights/Information:

The facility has no clients who are currently residing in the facility, therefore there are no physician orders to review.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

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: A PLACE TO HEAL	FACILITY NUMBER: 198603537
	VISIT DATE: 05/23/2023

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Client Records/Incident Reports:

· The facility has no clients who are currently residing in the facility, therefore there are no records to review.

Food Service:

· The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.

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

Health Related Services:

· There are no clients living in the facility so it cannot be assessed if self-administration of prescription and non-prescription medications is required.

· There were no medication records that were reviewed because the facility currently does not have any clients.

Incident Medical and Dental:

· There are no clients admitted into the facility currently so there were no vaccination cards on file.

· There were no staff currently so no training was on file.

Disaster Preparedness, and Emergency Intervention:

· A posted Emergency Disaster Plan LIC 610D containing emergency evacuation information was observed.

· There have been no clients at the facility so no disaster drills have been conducted.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies that were cited during the inspection. Exit interview was conducted and report provided.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC809 (FAS) - (06/04)

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