197607735-6-14-2024-11-AS-FSHY-D53QNC-20240508121857

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607735
Report Date: 05/08/2024
Date Signed: 06/14/2024 05:11:12 PM

Document Has Been Signed on 06/14/2024 05:11 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:	4219 W. 162ND STREET HOME		FACILITY NUMBER:	197607735
ADMINISTRATOR/ DIRECTOR:	MELANIE M ESTEPA		FACILITY TYPE:	740
ADDRESS:	4219 W. 162ND STREET		TELEPHONE:	(424) 247-8936
CITY:	LAWNDALE	STATE: CA	ZIP CODE:	90260
CAPACITY: 3		CENSUS: 3	DATE:	05/08/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Gabriela Vasquez, Nurse Consultant		TIME VISIT/ INSPECTION COMPLETED:	12:20 PM

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On 05/8/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced required annual visit using the full CAREs Inspection Tool. LPA met with Administrator, Melanie Estepa and explained the purpose of today’s visit. The facility is licensed to serve elderly developmentally disabled residents ages 60 years and older, cleared for three (3) non-ambulatory residents. During the time of visit all three (3) residents were present, involved in their virtual day program.

LPA reviewed all resident files and found they contained the required documents. LPA reviewed five (5) staff files and found they contained the required documents, training, and certification. LPA reviewed the surety bond. LPA reviewed the training logs for staff. LPA received a copy of the Liability Insurance.

LPA Felisa and Melanie toured both inside and outside of the facility. The facility is a one-story structure located in a residential neighborhood. The facility consists of (3) client bedrooms, (2) bathroom, living room, kitchen, dining area, patio, garage used for storage and laundry area. Facility maintains all required posting throughout the facility.

All bedrooms were toured. Bedrooms 1-3 are occupied by residents and contain the mandated furniture. LPA observed all rooms to have the required furniture including a bed, dresser(s), nightstand, and chair(s). All beds had the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillow. LPA observed ample lighting in all the bedrooms.

LPA Shirley and Melanie toured the kitchen and found it to be clean and sanitary. All appliances were in good working order. Knives were locked and stored. The medications were locked and stored in drawers in each of the resident’s rooms and inaccessible to the resident. LPA observed a 3-day supply of perishable and a 7-day supply of nonperishable foods. The water temperature measured 116.8 degrees Fahrenheit.

Con'd 809-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024

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: 4219 W. 162ND STREET HOME	FACILITY NUMBER: 197607735
	VISIT DATE: 05/08/2024

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The (2) bathrooms have grab bars and are clean and operational. First aid kit is fully stocked with manual. No firearms are stored at facility and no bodies of water present. This facility is in good repair.

LPA Shirley and Melanie walked through all common areas. In the living room, kitchen, dining room there is ample seating and space for all residents. All rooms and walkways were clean, and clear of obstructions and hazards. All areas have ample lighting. All rooms, hallway, and living room have working smoke detectors. There is a charged fire extinguisher in the kitchen. The backyard is clean and clear of obstructions and hazards, shaded patio area and there are no bodies of water present.

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

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024

LIC809 (FAS) - (06/04)

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