198204012-11-23-2021-11-AS-DSEA-C936E6-20211123194413

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198204012
Report Date: 11/23/2021
Date Signed: 11/23/2021 07:45:16 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	ATKINSON CARE HOME		FACILITY NUMBER:	198204012
ADMINISTRATOR:	MUQEET D. DADABHOY		FACILITY TYPE:	740
ADDRESS:	17035 ATKINSON AVENUE		TELEPHONE:	(310) 819-8218
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90504
CAPACITY:	6	CENSUS: 4	DATE:	11/23/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:26 PM
MET WITH:	Muqueet D. Dadabhoy		TIME COMPLETED:	03:30 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	On 11/23/2021, Licensing Program Analyst (LPA) Don Senaha conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with Licensee Muqueet Dadahboy and explained the purpose of today’s visit. The facility is licensed to operate for six (6) non-ambulatory residents age 60 and above of which six (6) can be hospice residents. The facility is two-story structure located in a residential neighborhood. It consists of the following: four (4) resident rooms, two (2) resident bathrooms, one (1) living area, one (1) dining area, kitchen, and outside patio area including a shed for storage and a table with shade. The second story of the facility is not accessible to residents and consists of an office space with a restroom and a staff rest/break room with a restroom. There is an additional refrigerator and freezer and the washer and dryer in the detached garage used for storage. LPA and Licensee toured the physical plant. There were no bodies of water or obstructions on the premises. There are ramps leading to the backyard for each resident room to exit the front yard. The front yard consists of a white gate separating the sidewalk and the property and a small waterfall on the left side of the house in the corner. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured between 105.0 F to 106.8 F in the bathrooms and kitchen sink. A comfortable temperature was maintained in the facility. Evaluation Report Continues on LIC 809-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Don Senaha	TELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ATKINSON CARE HOME	FACILITY NUMBER: 198204012
	VISIT DATE: 11/23/2021

NARRATIVE

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LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. There is a fully charged fire extinguisher in the kitchen, smoke detectors and carbon monoxide were operable. Medications were stored in a locked cabinet in the kitchen.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

No deficiencies were cited during this inspection visit.

An exit interview was conducted and a copy of this report was provided to Licensee Muqueet Dadahboy.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Don Senaha	TELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021

LIC809 (FAS) - (06/04)

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