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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607600
Report Date: 01/27/2022
Date Signed: 01/27/2022 03:18:06 PM

Document Has Been Signed on 01/27/2022 03:18 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:DIANE'S FAMILY & FRIENDSFACILITY NUMBER:
197607600
ADMINISTRATOR:DIANE SIGURFACILITY TYPE:
740
ADDRESS:11235 S. VAN NESS AVE.TELEPHONE:
(323) 755-6616
CITY:INGLEWOODSTATE: CAZIP CODE:
90303
CAPACITY: 4CENSUS: 3DATE:
01/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Diane SigurTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced required annual 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 with Licensee Diane Sigur and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved mitigation plan report. LPA Bunker verified all current staff fingerprints cleared/associated with the facility. There are currently three (3) Westside Regional Center (WRC), Residential Care Facility for the Elderly (RCFE) consumers in placement.

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."

Ms. Sigur and LPA Bunker both toured the inside and outside grounds of the facility.
The facility is a single-story family home located in a residential neighborhood. Ms. Sigur and LPA Bunker made a complete tour of the facility which consisted of a Living room, three (3) bedrooms, two (2) bathrooms, dining room, kitchen, laundry room, detached garage, shaded area, indoor/outdoor activity areas. Bedrooms #1-2 are designated as residents’ bedrooms.

See continued LIC809-C page #2
SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2022
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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: DIANE'S FAMILY & FRIENDS
FACILITY NUMBER: 197607600
VISIT DATE: 01/27/2022
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Continued LIC809-C page #2

Documents are posted as mandated on the dining room wall bulletin board. The following Title 22 Regulated areas were audited and found to be in compliance: Bedrooms contain the required furniture. Personal accommodations were observed for safety, privacy, and comfort, including grab bars, and non-skid surfaces mats. The living areas are clean, bathrooms are clean and operational. First aid kit is fully stocked with manual, hot water temperature 120 degrees Fahrenheit, working telephone, smoke and carbon monoxide detectors were in compliance, fire extinguishers are fully charged, medications were centrally stored and properly locked in the laundry room cabinet and records are current, ample supply of perishable and nonperishable food, adequate linen supply, fire/emergency drill conducted on January 26, 2022. No firearms on the premises, client's bedroom windows have no sliding window locks with thumbscrews, all exit doors were in compliance, covered trash cans, and no bodies of water present. Hazardous items are inaccessible to clients, the yard is free of debris and hazards.

The administrator stated staff was given training on dependent adult and elder abuse reporting.

There were no deficiencies cited.

Exit interview conducted.
SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022
LIC809 (FAS) - (06/04)
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