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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607735
Report Date: 05/28/2021
Date Signed: 06/01/2021 12:40:57 AM

Document Has Been Signed on 06/01/2021 12:40 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:4219 W. 162ND STREET HOMEFACILITY NUMBER:
197607735
ADMINISTRATOR:CHARMILEY VENTURAFACILITY TYPE:
740
ADDRESS:4219 W. 162ND STREETTELEPHONE:
(424) 247-8936
CITY:LAWNDALESTATE: CAZIP CODE:
90260
CAPACITY: 3CENSUS: 3DATE:
05/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Melanie EstapaTIME COMPLETED:
03:15 PM
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On 5/28/2021 at 1:10 pm, Licensing Program Analyst (LPA) Lourdes Montoya 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 Montoya called the facility and spoke with Malanie Estepa and conducted a risk assessment over the telephone. Based on the assessment, the facility is clear of Covid-19 infection. LPA verified that the facility has an approved mitigation plan report.

Administrator Charmiley Andres certificate expires on 08/21/2022 / #6003016740.

The facility is licensed to serve elderly developmentally disabled residents ages 60 years and older, cleared for three (3) non-ambulatory residents. Currently, there are three residents and 3 staff present in the home during today’s visit.

At 1:20 pm, LPA met with caregiver Maryann and they both toured the inside and outside grounds of the facility. LPA was properly screened for Covid-19 symptoms and temperature was checked. The House Manager, Melanie Estepa, arrived shortly and assisted LPA with the tour.

During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance; visitors log with Covid-19 screening and temperature log, and records of daily Covid-19 screening and temperature checks of residents and staff. PPE supplies are readily available to staff, and an additional 30-day supply of PPE is stored in the garage; sufficient paper, cleaning, and disinfecting supplies were observed. The facility’s designated visitation area is the back patio in addition to the resident’s bedroom. LPA observed residents and staff maintain 6 feet physical distancing, and each staff wears a face covering. LPA observed required postings throughout the facility.

LPA reviewed the facility’s surveillance testing records, 25% of all staff was tested every 7 days. An emergency contact list was reviewed.

REPORT CONTINUED IN LIC 809-C

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 05/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2021
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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME: 4219 W. 162ND STREET HOME
FACILITY NUMBER: 197607735
VISIT DATE: 05/28/2021
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All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed. Furniture in the living room are all in good condition. There are no security bars or weapons on the premises. 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, and a non-skid mat was in place. The water temperature was measured at 119.4 degrees F. in both bathrooms. A comfortable temperature was maintained in the facility.

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. Centrally stored medications were observed stored in their originally received containers and kept safe and locked and inaccessible to clients in care. The First Aid kit was available. One fire extinguisher last serviced on 6/17/2020 is fully charged.

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.

Advisory Notes were issued, and Technical Assistance was provided.

An exit interview was conducted, and a copy of this report was provided to the House Manager, Melanie Estepa.

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021
LIC809 (FAS) - (06/04)
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