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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607600
Report Date: 01/30/2023
Date Signed: 01/30/2023 03:16:12 PM

Document Has Been Signed on 01/30/2023 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, 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:
01/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:59 PM
MET WITH:Diane Sigur - AdministratorTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mario Leon conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA was met by Diane Sigur, Administrator. The purpose of today’s visit was explained. The facility is licensed to serve 4 elderly clients (aged 60 and above).

There are currently (3) elderly clients in placement. All three (3) clients are ambulatory. The facility is a single-story structure located in a residential neighborhood. Mrs. Sigur and LPA Leon made a complete tour of the facility which consisted of the following: Living room, three (3) bedrooms, two (2) bathrooms, dining area, kitchen, laundry room, detached garage, shaded area, indoor/outdoor activity areas. Bedrooms #1-2 are designated as the client's bedrooms. Bedroom #1 hosts two (2) clients, Bedroom #2 has one female client.

LPA and administrator toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were clean and operational, yet outside of Title 22 regulations. The water temperature measured 153.5 F in bathroom #2. A comfortable temperature is maintained in the facility at 69 F. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is enough perishable and non-perishable food available, which is stored properly. Fire extinguisher was charged, smoke detectors and Carbon Monoxide need to be updated.

SEE LIC 809-C
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2023
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 4
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: DIANE'S FAMILY & FRIENDS
FACILITY NUMBER: 197607600
VISIT DATE: 01/30/2023
NARRATIVE
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During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations (located in common areas and restrooms). LPA observed staff were wearing face coverings, an isolation room and required postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE), located in the detached garage.

LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PINs) for any updates relating to COVID-19 guidance.



During today’s visit there were two deficiencies cited, see LIC809-D.

Exit interview held with Diane Sigur. A copy of the report was provided to Diane Sigur, Administrator.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 01/30/2023 03:16 PM - It Cannot Be Edited


Created By: Mario Leon On 01/30/2023 at 02:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: DIANE'S FAMILY & FRIENDS
FACILITY NUMBER: 197607600

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above in that the water temperature has been measured at 153.5 F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2023
Plan of Correction
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LPA and Administrator have agreed that Administrator will submit media proof (photo/video), via email to Felisa.Shirley@DSS.CA.GOV, of the water temperature within Title 22 regulations (105F-120F) to CCLD as soon as possible, but not after the POC due date which is 2/06/23
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 01/30/2023 03:16 PM - It Cannot Be Edited


Created By: Mario Leon On 01/30/2023 at 02:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: DIANE'S FAMILY & FRIENDS
FACILITY NUMBER: 197607600

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(2)
Personal Accommodations and Services
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above in that all smoke and carbon monoxide alarms are in disrepair, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2023
Plan of Correction
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LPA and Administrator have agreed that the current alarm system will be repaired within the next week. Administrator has contacted ADT alarm service. ADT has agreed to send a technician to arrive at the facility on 2/02/23 between 8:00AM-12:00PM. Administrator will submit a copy of the work order to CCLD, by email, at Felisa.Shirley@DDS.CA.GOV
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
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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:Ulysses Coronel
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2023


LIC809 (FAS) - (06/04)
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