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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198203121
Report Date: 06/03/2024
Date Signed: 06/03/2024 02:36:39 PM

Document Has Been Signed on 06/03/2024 02:36 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:JOSEPHINES GARDEN VILLAFACILITY NUMBER:
198203121
ADMINISTRATOR/
DIRECTOR:		FRANCES REEDERFACILITY TYPE:
740
ADDRESS:521 N. ROWELL AVENUETELEPHONE:
(310) 376-5758
CITY:MANHATTAN BEACHSTATE: CAZIP CODE:
90266
CAPACITY: 6CENSUS: 5DATE:
06/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Rissa AngeraniTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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On 06/03/24 Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced Annual required visit using the CARE Tool. LPA met with Rissa Angerani, Caregiver and the purpose of today’s visit was explained. LPA was granted access to the facility. Facility is licensed to serve six (6) residents aged 60 and above, five (5) non-ambulatory and one (1) bedridden. There are currently five (5) residents in the facility.

The facility is a single-story home located in a residential neighborhood. The facility consists of six (6) bedrooms, one (1) staff room, four (4) bathrooms including a separate shower room for residents, a living room, dining room, kitchen, laundry area, and an attached garage with a backyard shaded area.

LPA Gonzalez and Rissa Angerani toured the inside and outside grounds of the facility. There were no bodies of water or obstructions on the premises. Resident bedrooms had the required furniture, and adequate lighting was provided. LPA observed bed linens and closet/drawer space to accommodate each resident comfortably. Bathrooms were checked and found to be within title 22 regulations and were operational. The water temperature measured between 105.0 F and 120.0 F in all bathrooms. LPA observed linens, bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. A comfortable temperature was maintained in the facility.

The kitchen was inspected and there is sufficient perishable and non-perishable food supply maintained adequately. All sharps, toxins, cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. LPA Gonzalez observed the facility to be sanitary and appropriately furnished at the time of the visit. Medications were centrally stored and properly locked. A review of Medication Administration Records was maintained in order and accurate.

Continued on LIC809-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE: DATE: 06/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/03/2024
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: JOSEPHINES GARDEN VILLA
FACILITY NUMBER: 198203121
VISIT DATE: 06/03/2024
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The facility has a landline telephone on-site in working condition. Smoke detectors and carbon monoxide detectors were operational and working properly. Fire extinguishers were charged and operable. LPA observed a stocked First Aid kit along with manual.

During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents. There are 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.

During this inspection LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview was conducted, and a copy of the Report and Appeal Rights was provided to Rissa Angerani, Caregiver.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2024
LIC809 (FAS) - (06/04)
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