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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197800100
Report Date: 11/09/2023
Date Signed: 11/28/2023 04:12:23 PM

Document Has Been Signed on 11/28/2023 04:12 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:CARSON GUEST HOMEFACILITY NUMBER:
197800100
ADMINISTRATOR:RESURRECCION, CORAZONFACILITY TYPE:
740
ADDRESS:22418 CATSKILL AVENUETELEPHONE:
(310) 830-2518
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 6CENSUS: 6DATE:
11/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:09 AM
MET WITH:Cora ResurreccionTIME COMPLETED:
12:30 PM
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On 11/09/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with administrator Cora Resurreccion and explained the purpose of today’s visit. The facility is licensed to operate for six (6) non-ambulatory of which one (4) may be on hospice elderly residents ages 60 and above. The facility is approved for (4) hospice residents. Currently, the facility has (3) residents in hospice care.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident's rooms, two (2) common bathrooms, a living area, a dining area, a kitchen, and an outside covered patio area.

LPA and administrator toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 116.0 degree F. A comfortable temperature of 70 degree was maintained in the facility.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. Fire extinguisher were charged, smoke detectors and carbon monoxide were operable. A review of the Medication Administration Record (MAR) was complete and accurate. The facility has conducted a disaster drill on 11/04/23. A landline telephone was in working condition. A review of staff CPR/First Aid training is current.
Evaluation Report Continues LIC 809-C
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2023
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 2
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: CARSON GUEST HOME
FACILITY NUMBER: 197800100
VISIT DATE: 11/09/2023
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA observed First Aid Kit was maintained. The facility has current liability insurance on file effective 08/15/23 - 08/15/24. The facility is current on Community Care Licensing annual dues.

An audit of residents #1-#6 (R1-R6) service files and staff #1-#6 (S1-S6) personnel files revealed to be complete. The facility has the current administrator's certification on file for Cora Ressurreccion #6049380740- Expiration 10/03/24.

No deficiencies during this inspection visit.

An exit interview was conducted with Cora Ressurreccion, and a copy of the report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023
LIC809 (FAS) - (06/04)
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