198602559-4-14-2022-11-AS-JCAS-CDDUHT-20220411153627

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602559
Report Date: 04/11/2022
Date Signed: 04/14/2022 10:47:36 AM

Document Has Been Signed on 04/14/2022 10:47 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME:	GARTH HOME		FACILITY NUMBER:	198602559
ADMINISTRATOR:	WEINGARTEN, GOLDA		FACILITY TYPE:	734
ADDRESS:	5505 S GARTH AVE		TELEPHONE:	(650) 238-4987
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90056
CAPACITY:	5	CENSUS: 5	DATE:	04/11/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:28 PM
MET WITH:	Golda Weingarten		TIME COMPLETED:	03:50 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 (LPAs) Jey Cardenas and Jade Jordan conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA Cardenas met with staff, R.Joseph; LPA conducted a risk assessment, based on the assessment, the facility is clear of Covid-19 infection. Administrator, Weingarten, Golda arrived shortly after and assisted LPAs, the purpose of todays visit was explained. The facility is licensed for five (5) non-ambulatory of which five may be bedridden.

The facility is a one story residential house consists of 5 bedrooms and two bathrooms half bathroom, office space, dining area, living room, kitchen, the garage.

During the tour, LPA observed the facility’s infection control practices. LPA verified that the facility has an approved mitigation plan report. LPA was properly screened for Covid-19 symptoms, temperature was checked and documented. LPA observed a sanitizing station at the facility entrance; visitors log with Covid-19 screening and temperature log, PPE supplies are readily available to staff, and an additional 90 day supply of PPE was observed in the garage area. Sufficient paper, cleaning, and disinfecting supplies were observed. The facility’s designated visitation area is the shaded backyard area. LPA observed all staff wear a face covering. LPA observed required postings throughout the facility. CCLD PINS were readily available to staff and clients.

All rooms were inspected, bedrooms are private, one client per room. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed.

Resident bathrooms were checked, sufficient liquid soap and paper towels were observed. Toilets and water faucets worked properly, grab bars were secure, the shower was free of mold/mildew, the water temperature measured at 107.4 degrees F in bathroom. Comfortable temperature was maintained in the facility. On 4/11/22 LPA observed three (3) razors in unlocked hygine shower cabinetry which is located in .

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey Cardenas	TELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022

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 3

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
MONTERY PARK, CA 91754

FACILITY NAME: GARTH HOME	FACILITY NUMBER: 198602559
	VISIT DATE: 04/11/2022

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

bathroom. LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in a locked storage cabinet. Dual carbon Monoxide and interconnected Smoke Detectors were tested, and in operating condition. The facility has one (1) Fire Extinguisher, which was checked and found to be fully charged, accessible, and inspected Jan 2022. The First Aid kit was available and fully stocked. There are no security bars or weapons on the premises.

Outside grounds were toured, and no bodies of water were observed. Walkways around the home were clear of hazards. Common areas were clean and clear of hazards; doorways were free of obstructions. No bodies of water present.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey Cardenas	TELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 04/14/2022 10:47 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: GARTH HOME	FACILITY NUMBER: 198602559
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087

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 in, On 4/11/22 LPA observed razors in the bathroom accessible to clients which poses/posed a potential health, safety rights risk to persons in care.
	POC Due Date: 04/11/2022
	Plan of Correction
1 2 3 4	Facility removed razors at the time of visit

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.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey Cardenas	TELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3