198601930-11-14-2022-11-AS-PBUR-CL6PDT-20221114101405

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601930
Report Date: 07/07/2022
Date Signed: 11/14/2022 10:14:30 AM

Document Has Been Signed on 11/14/2022 10:14 AM - 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	FLAGSHIP @ LA SALLE		FACILITY NUMBER:	198601930
ADMINISTRATOR:	CAFFEY, SHERITA		FACILITY TYPE:	735
ADDRESS:	9129 LA SALLE AVE		TELEPHONE:	(323) 920-6523
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90047
CAPACITY:	3	CENSUS: 3	DATE:	07/07/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Sherita Rembert		TIME COMPLETED:	12:30 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	Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced required 1- year visit with the primary focus on Infection Control measures and using the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA was properly screened for COVID-19 symptoms and temperature was checked. LPA Bunker met Administrator Sherita Rembert and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved mitigation plan report. There are currently four (3), South Central Los Angeles Regional Center (SCLARC) Adult Residential Care Facility (ARF) consumers in placement. The facility's annual fees are current. The following Domain will be observed and reviewed: Infection Control Practices "I will be using this tool and methods that have been developed to improve the efficiency and accuracy of the Department of Social Services' facility inspections." The facility is a single-family home located in a residential neighborhood. Administrator Sherita and LPA Bunker toured the facility which consisted of the following: Living room, kitchen, dining room, office area, 3 bedrooms, 1 ½ bathrooms, laundry room, detached garage, shaded area, and indoor/outdoor activity area. The front and back yard landscape is in good condition at the time of the visit. See continued LIC809-C on page 2

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: FLAGSHIP @ LA SALLE	FACILITY NUMBER: 198601930
	VISIT DATE: 07/07/2022

NARRATIVE

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Continued LIC809-C page 2

Documents are posted as mandated. Bedrooms contain the furniture mandated. The bathrooms are clean and operational. Personal accommodations were observed for safety, privacy, and comfort. The kitchen was observed for its ability to prepare and serve food. The food service was reviewed for appropriate quantity and proper storage; there was an ample supply of perishable and nonperishable food. The resident’s medications were reviewed for proper storage, documentation, and system implementation. Medications are locked, and records are current. Common areas observed for the ability to safely serve the needs of the residents, including cleanliness, and clear of any potential hazards to the residents. The first aid kit is fully stocked with manual, smoke, and carbon monoxide detectors were in compliance, the hot water temperature was measured at 105 degrees Fahrenheit within the normal limits (105-120F degrees), the fire extinguisher is fully charged, adequate linen supply, the facility telephones are working, resident. The client's bedroom windows have no sliding window lock with thumbscrews, all exit doors were in compliance, the yard was free of debris hazards, and trash cans were covered. Staff was given training on dependent adult and elder abuse reporting. The facility conducted a fire drill on July 01, 2022.

The following deficiencies of the California Code of Regulations, Title 2, Division 6, Chapter 1 are cited on the attached LIC809-D. Appeal Rights issued and discussed.

Exit interview conducted.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/14/2022 10:14 AM - 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: FLAGSHIP @ LA SALLE	FACILITY NUMBER: 198601930
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited


	Deficient Practice Statement
1 2 3 4	80087 (a) Buildings and Grounds: The facility shall be clean, safe, sanitary, and in good repair at all times for the safety, and well-being of clients, employees and visitors. The facility carpet in the living room, hallway, and bedrooms, high traffic area has wear and tear, stains with dark brown and black spots.
	POC Due Date: 08/31/2022
	Plan of Correction
1 2 3 4	The licensee needs to replace the carpet in the facility's living room, hallway, and bedrooms. The violation poses a potential health and safety risk to residents in care.

Section Cited


	Deficient Practice Statement
1 2 3 4	80087 (a) Buildings and Grounds: The facility shall be clean, safe, sanitary, and in good repair at all times for the safety and well-being of clients, employees, and visitors. The vent hoods over the stove are rusty and have brown, oil, and grease stains.
	POC Due Date: 07/28/2022
	Plan of Correction
1 2 3 4	The licensee needs to replace the vent hoods over the stove. The violation poses a potential health and safety risk to residents in care.

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

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022

LIC809 (FAS) - (06/04)

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