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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607735
Report Date: 11/18/2022
Date Signed: 11/22/2022 11:30:24 AM

Document Has Been Signed on 11/22/2022 11:30 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:4219 W. 162ND STREET HOMEFACILITY NUMBER:
197607735
ADMINISTRATOR:MELANIE M ESTEPAFACILITY TYPE:
740
ADDRESS:4219 W. 162ND STREETTELEPHONE:
(424) 247-8936
CITY:LAWNDALESTATE: CAZIP CODE:
90260
CAPACITY: 3CENSUS: 3DATE:
11/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:58 PM
MET WITH:Melanie EstepaTIME COMPLETED:
04:15 PM
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On November 18, 2022, Licensing Program Analyst (LPA) Wendy Gibbs conducted an unannounced required annual visit with a primary focus on Infection Control measures using the CARE Inspection Tools. LPA met with Melanie Estepa and explained the purpose of the visit. 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.

Structure The facility is a single story home in a residential neighborhood. The facility has three (3) client rooms, two (2) bathrooms, kitchen, dining room, living room, office space, and a detached garage.

Physical Plant LPA walked the outside of the facility. In the back there are table and chairs available for use. LPA did not observe any bodies of water. All walkways were clear, free of obstructions and debris.

Bedrooms All bedrooms have the required furniture. Each room contained a bed, dresser(s), nightstand, closet space, and chair(s). There was adequate lighting in the bedroom.

Bathrooms Both bathrooms were inspected and meet regulations. The toilet, sink and showers are in good working order. The grab bars were secured, and a nonskid mat and chair were available in the shower. The water temperature measured 118.3-119.1 degrees Fahrenheit.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2022
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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: 4219 W. 162ND STREET HOME
FACILITY NUMBER: 197607735
VISIT DATE: 11/18/2022
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Kitchen All appliances are in good working condition. LPA observed three (3) day supply of perishable and seven (7) day supply of nonperishable food. Water temperature measured 119.1 degrees Fahrenheit. Knives are locked in a drawer in the kitchen.

Linens & Hygiene Extra linens were stored in each client’s individual closets. Also towels and personal products (diapers, mats) were stored in client’s closets. Additional hygiene products were stored in a cabinet in the bathroom.

Cleaning Supplies All cleaning supplies and additional cleaning equipment were stored in the hall closet.

Safety The smoke/carbon monoxide detectors were in good working order. There is a full charged fire extinguisher in the kitchen. The First Aid kit was inspected and contained all required items with the manual. The last emergency drill the facility had was on 11/3/22. Egress systems on all doors were in good working order.

File Review LPA reviewed all resident files. All files contained the required documents. Three staff files were reviewed and contained the required and up to date documents.

Medications Centrally stored medications were observed stored in their originally received containers and kept safe and locked and inaccessible to clients in care. LPA reviewed the MARs and medications for each resident.

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 90-day supply of PPE is stored in the garage; sufficient paper, cleaning, and disinfecting supplies were observed.

LPA reviewed the Liability Insurance and it is good till 8/23/23.

No deficiencies were cited. Exit interview was conducted with Melanie Estepa.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022
LIC809 (FAS) - (06/04)
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