197606934-2-26-2025-11-AS-PSCT-DE9VAW-20250226151637

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606934
Report Date: 02/26/2025
Date Signed: 02/26/2025 03:16:45 PM

Document Has Been Signed on 02/26/2025 03:16 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:	CELEBRITY CARE HOME		FACILITY NUMBER:	197606934
ADMINISTRATOR/ DIRECTOR:	CARMELITA M. BAUTISTA		FACILITY TYPE:	740
ADDRESS:	233 W. 234TH STREET		TELEPHONE:	(310) 830-8366
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY: 6		CENSUS: 5	DATE:	02/26/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:21 PM
MET WITH:	Carmelita Bautista		TIME VISIT/ INSPECTION COMPLETED:	03:30 PM

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On 2/26/2025, at 1:21pm, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced annual required visit using the new CARE Inspection Tool. LPA met with Carmelita Bautista, Licensee, and explained the purpose of today’s visit. The facility is licensed to operate for four (4) non-ambulatory and two (2) bedridden elderly residents ages 60 and above. The facility is approved for (3) hospice residents. Currently the facility has (5) residents. The facilities annual fees are due on 03/26/25 for $495.00.

The facility is a single-story home and consists of the following: three (3) resident bedrooms, two (2) bathrooms one (1) of which is for residents and one (1) is for visitors and staff. Additionally, there is a living room, kitchen, dining room, attached garage, washer and dryer, and an additional refrigerator for extra food storage, and an outdoor shaded area with patio and chairs.

LPA conducted a records review of four (5) residents records, four (4) staff records, and reviewed the facility disaster plan. All resident & staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. The fire/emergency drill was completed on 1/24/2025. LPA reviewed (5) resident Medication Administration Records and medication and did not observe any discrepancies at the time of visit. The facilities administrator certificate was current and expires on 4/25/2025. LPA observed that the facility has current liability insurance which expires on 12/26/2025.

At 1:45pm, LPA and the administrator toured the facility. All resident rooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed, walls and floors were clean and in good repair, bed linens, comforters and bath towels were fully stocked. Bathrooms were found to be within Title 22 regulation, toilets, and water faucets worked properly, shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature measured between 105-117.3F degrees.

Facility Evaluation Report Continued On Page 2 of the LIC809-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025

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: CELEBRITY CARE HOME	FACILITY NUMBER: 197606934
	VISIT DATE: 02/26/2025

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Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide detector was observed and operational. Smoke detectors were working properly, two (2) fire extinguishers were fully charged, one (1) located and mounted in the hallway and one (1) located in the kitchen; toxins and knives were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked, and the first aid manual was up to date. A landline telephone was observed. Outside grounds were toured and no bodies of water were observed. Exits/ Walkways around the home were free of debris and hazards.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents. LPA observed that sanitizing stations were in common areas and restrooms. LPA observed that the facility had the required postings, posted throughout the facility. LPA further observed the facility to have a 30-day supply of Personal Protective Equipment (PPE).

LPA advised the administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing (www.cdss.ca.gov) for Provider Informational Notices (PIN) and for any updates relating to COVID-19 guidance and other related issues.

During today’s visit LPA did not observe any deficiencies.

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Carmelita Bautista, Licensee.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025

LIC809 (FAS) - (06/04)

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