197803954-11-8-2024-11-AS-DLEE-DATVZL-20241108155255

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197803954
Report Date: 11/08/2024
Date Signed: 11/08/2024 03:53:11 PM

Document Has Been Signed on 11/08/2024 03:53 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	AMYTONY HOME IV		FACILITY NUMBER:	197803954
ADMINISTRATOR/ DIRECTOR:	MELANIE ESTEPA		FACILITY TYPE:	735
ADDRESS:	1924 SHIPWAY AVENUE		TELEPHONE:	(562) 795-9162
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90815
CAPACITY: 4	TOTAL ENROLLED CHILDREN: 0	CENSUS: 3	DATE:	11/08/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:53 PM
MET WITH:	Maria Sunio		TIME VISIT/ INSPECTION COMPLETED:	04:00 PM

NARRATIVE

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On November 8, 2024, Licensing Program Analyst (LPA) Deborah Lee conducted an unannounced required annual visit using the CARE Inspection Tools. LPAs met with Maria Sunio and explained the purpose of this visit. The facility is licensed to serve 4 Non-Ambulatory clients ages 18-59. Currently, there are 3 Harbor Regional Center Clients in placement.

Structure The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) client’s rooms, two (2) common bathrooms, living area, dining area, kitchen, and outside covered patio area.

Physical Plant LPA and Maria Sunio toured the facility inside and outside. LPA observed There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the resident's personal belongings was observed. LPA observed that facility had required postings: Facility license, personal rights, facility sketch, exit signs, infectious disease postings, emergency disaster plan.

Bedrooms LPA inspected all (4) private bedrooms All bedrooms were observed to have the required furniture including beds, dressers, night stands with lamps, chairs, and ample storage space for personal belongings. All bedrooms were observed to be clean, in good repair, and have ample lighting.

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Eva M Alvarez	TELEPHONE: (323) 629-7047
Deborah Lee	TELEPHONE: (424) 544-1051
	DATE: 11/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024

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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: AMYTONY HOME IV	FACILITY NUMBER: 197803954
	VISIT DATE: 11/08/2024

NARRATIVE

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Bathrooms LPA inspected the facility bathrooms. In the resident’s bathroom the toilet, faucets, and shower were fully operational. LPA observed the showers to be clean and free of mold or mildew. The water temperature measured 112.2 degrees Fahrenheit. The toilet and faucets are operational. All bathrooms were observed to be clean, in good repair and within Title 22 regulations.

Linens & Hygiene LPA observed all beds to have the required linens including mattress cover, fitted sheets, blanket, comforter, and pillow. LPA observed an ample supply of linens, towels, and blankets in hall closet.

Kitchen LPA inspected the kitchen and observed most appliances to be in good working repair, except the stove (deficiency documented on 809D). LPA observed an ample supply of cutlery, pots, pans, and bowls to be in good repair. LPA observed knives and additional sharps to be secured in locked drawers in the kitchen and are inaccessible to residents. LPA observed a 3-day supply of perishable foods and a 7-day supply of nonperishable foods.

Common Rooms In the living room area LPA observed sofa, and 2 chairs, television, a. Dining table is in kitchen/office space area of the home. An office area located Adjacent to the kitchen area which contained computer desk chair and file cabinet.

Safety LPA observed and tested smoke/carbon monoxide detectors to be fully operable. LPA observed (1) fully charged fire extinguishers. LPA inspected the First Aid kit and found it contained an ample supply of required items: Scissors, tweezers, gauze, disinfectant wipes, band aids. LPA observed all exits to be clear and easily accessible. Last fire drill conducted on 9/11/24.

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SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Deborah Lee	TELEPHONE: (424) 544-1051
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024

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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: AMYTONY HOME IV	FACILITY NUMBER: 197803954
	VISIT DATE: 11/08/2024

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Medications LPA observed all centrally stored medications in their original packaging and are secured in a locked cabinet that is inaccessible to Residents in care.

Files LPA reviewed ( 3) resident files and found that (3) out of (3) contained all the necessary documentation. LPA reviewed (3) staff files and found that (3) out of (3)contained the required documentation, certification, and training.

Infection Control During the visit, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance. PPE supplies are readily available to staff.

Deficiency was issued and an exit interview is conducted with Maria Sunio. A copy of this report is provided along with the appeal rights.

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SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Deborah Lee	TELEPHONE: (424) 544-1051
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 11/08/2024 03:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: AMYTONY HOME IV	FACILITY NUMBER: 197803954
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Building and Grounds

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) ], the licensee did not comply with the section cited above During physical plant walk through, LPA observed bathroom spray in bathroom assessable to clients in care.which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/08/2024
	Plan of Correction
1 2 3 4	Administrator removed and secured the bathroom spray and locked it away, so that it is inaccessible to clients in care.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Eva M Alvarez	TELEPHONE: (323) 629-7047
Deborah Lee	TELEPHONE: (424) 544-1051
	DATE: 11/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 11/08/2024 03:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: AMYTONY HOME IV	FACILITY NUMBER: 197803954
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Food Service

(a) In facilities providing meals to clients, the following shall apply: (7) Commercial foods shall be approved by appropriate federal, state and local authorities. All foods shall be selected, transported, stored, prepared and served so as to be free from contamination and spoilage and shall be fit for human consumption. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above as During physical plant inspection, LPA observed expired dry good in the cabinet. On two items had an expiration date of May 2024.which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/08/2024
	Plan of Correction
1 2 3 4	Administrator discarted the expired items at time of visit.

Section Cited

Food Service

(a) In facilities providing meals to clients, the following shall apply: (19) All equipment, fixed or mobile, dishes, and utensils shall be kept clean and maintained in safe condition. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observatio, the licensee did not comply with the section cited above as During physical plant walk through, LPA observed the stove not functioning properly. Staff have to light a match to the burner in order for it to activate.which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/09/2024
	Plan of Correction
1 2 3 4	LPA and Administrator agreed to have administrator repair or replace stove by 12/9/2024. LPA requested that Administator send a copy of the service invoice via email to LPA Deborah.Lee@dss.ca.gov.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Eva M Alvarez	TELEPHONE: (323) 629-7047
Deborah Lee	TELEPHONE: (424) 544-1051
	DATE: 11/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024

LIC809 (FAS) - (06/04)

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