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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607893
Report Date: 10/26/2021
Date Signed: 10/26/2021 02:28:28 PM

Document Has Been Signed on 10/26/2021 02:28 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:C-H #6 RESIDENTIAL CARE FOR ELDERLYFACILITY NUMBER:
197607893
ADMINISTRATOR:FISHER-ASHLEY, ADLEANFACILITY TYPE:
740
ADDRESS:8726 DORIAN STTELEPHONE:
(562) 633-3612
CITY:DOWNEYSTATE: CAZIP CODE:
90242
CAPACITY: 4CENSUS: 0DATE:
10/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Adlean Fisher-AshleyTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Spencer conducted an unannounced annual inspection focusing on the Infection Control Domain. LPA Spencer met with administrator Adlean Fisher-Ashley and discussed the purpose of today's visit. This single-story home contains two (2) client bedrooms, an office, two (2) bathrooms, a living room, kitchen, dining area, attached garage, and backyard.
The following was observed/inspected:
  • The facility had a universal entrance screening area including a thermometer, sign-in log, and PPE.
  • COVID-19 signage was placed in several areas and temperature logs were maintained.
  • Facility maintained a 30-day supply of PPE.
  • There was a sufficient supply of 7-day supply of non-perishable foods, but insufficient supply of non-perishable foods due to no fresh fruits. The staff picked up more food items prior to the end of visit.
  • All areas were clean and in good repair.
  • Sharps and cleaning solutions were locked and inaccessible.
  • Each room contained required furniture: bed, dresser, night stand, lamp/light and chair.
  • All beds contained the required linen: mattress cover, fitted sheet, flat sheet, blanket, and comforter.
  • Bathrooms contained supplies including liquid soap, toilet paper, and paper towels.
  • Medications were locked and centrally stored. There was missing medication for one (1) resident: empty container of Lactulose 10g/15 mL was observed. The administrator ordered and had medication delivered prior to the end of the visit.
  • Smoke detectors/carbon monoxide detectors were present and operable.
  • A fire extinguisher was observed to be fully charged and last serviced February 2021.
  • All client files were inspected: emergency contact information and physician's reports were up-to-date.
  • All staff files were inspected and contained required health screenings, criminal record clearances, first aid/CPR certificate, and training certificates. An updated administrator certificate was observed and expires on 5/23/2023.
Pursuant to Title 22, a deficiency was cited on attached 809D. An exit interview was conducted and a copy of this report and Appeal Rights were provided to the licensee.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: LaJean Nicole Spencer
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2021
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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Document Has Been Signed on 10/26/2021 02:28 PM - It Cannot Be Edited


Created By: LaJean Nicole Spencer On 10/26/2021 at 02:10 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: C-H #6 RESIDENTIAL CARE FOR ELDERLY
FACILITY NUMBER: 197607893

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above due to lack of fresh fruit perishable food which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2021
Plan of Correction
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The administrator had a staff member to pick up more supply of perishable foods including fresh fruit. This deficiency was cleared prior to the end of the visit.
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above for one out of three residents due to an empty container of Lactulose 10 g/15 mL which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2021
Plan of Correction
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The administrator immediately called the pharmacy to order the medication and have another supply delivered to the facility. This deficiency was cleared prior to the end of the visit.
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:Christine Yee
LICENSING EVALUATOR NAME:LaJean Nicole Spencer
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2021


LIC809 (FAS) - (06/04)
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