<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320046
Report Date: 03/30/2023
Date Signed: 03/30/2023 03:35:44 PM

Document Has Been Signed on 03/30/2023 03:35 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:DROCK HOME CAREFACILITY NUMBER:
198320046
ADMINISTRATOR:ADAMSON RUKAYATFACILITY TYPE:
740
ADDRESS:1652 E CYRENE DRIVETELEPHONE:
(310) 997-8046
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY: 6CENSUS: 6DATE:
03/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:49 AM
MET WITH:Rukayat AdamsonTIME COMPLETED:
04:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 03/30/23, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced annual required visit using the new Cares Inspection Tool. LPA met with licensee, Rukayat Adamson and explained the purpose of the visit. The facility is licensed to serve residents age range 60 and over, six (6) ambulatories, of which 6 may be non-ambulatory and a hospice waiver for 4. The current resident census is six (6). The facility has an outstanding balance of $742.00 for annual fees due, which include a late payment penalty.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: 5 bedrooms ( three (3) resident bedrooms and 2 staff rooms), (2) bathrooms ((1) staff and (1) resident bathroom), living room, dining room, kitchen, attached two car garage, and back yard patio with table and six chairs. Each resident bedroom has two residents residing. LPA toured the physical plant with licensee. 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 provided, storage for client 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 hot water temperature measured 109.3 degrees Fahrenheit. A comfortable temperature 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 clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. LPA observed that the fire extinguisher was charged. The smoke detectors and carbon monoxide are operable. Fire Drills were observed to be maintained in order and accurate. Last fire drill was conducted on 3/14/23. Exits/ Walkways around the home were free of debris and hazards.

Report continued on LIC809-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2023
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 3
Document Has Been Signed on 03/30/2023 03:35 PM - It Cannot Be Edited


Created By: Perry Scott On 03/30/2023 at 02:41 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: DROCK HOME CARE
FACILITY NUMBER: 198320046

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks.  Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.  A report shall be made of each screening, signed by the examining physician.  The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health.  Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 1 staff, Eyiuche Ewelukwa is missing a health screening in her file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/15/2023
Plan of Correction
1
2
3
4

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:Janae Hammond
LICENSING EVALUATOR NAME:Perry Scott
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
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: DROCK HOME CARE
FACILITY NUMBER: 198320046
VISIT DATE: 03/30/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Medications were centrally stored and properly locked, first aid kit was checked and fully stocked with manual. Client and staff files were reviewed. All staff are fingerprint cleared and associated to the facility and have documentation of the required trainings on file. However, the staff member did not have a health screening in the personnel file and is being cited for that deficiency.

LPA conducted a records review of (6) client records, (1) staff records, and reviewed the facility disaster plan. All client & staff records were complete, minus a health screening. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (6) Client Medication Administration Records and did not observe any discrepancies at the time of visit.

During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a 60-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff and resident temperature logs were reviewed.

The following deficiencies were cited during this visit:

87411(f) Personnel Requirements-General (No health screening for staff member)

An exit interview was conducted, and a copy of this report was provided to Licensee, Rukayat Adamson

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3