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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320191
Report Date: 07/13/2021
Date Signed: 07/13/2021 01:35:38 PM

Document Has Been Signed on 07/13/2021 01:35 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME:FORT FAITH RCFEFACILITY NUMBER:
198320191
ADMINISTRATOR:FORT, NISHAFACILITY TYPE:
740
ADDRESS:710 LACONIA PL.TELEPHONE:
(213) 362-8837
CITY:LOS ANGELESSTATE: CAZIP CODE:
90044
CAPACITY: 6CENSUS: 0DATE:
07/13/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Nisha FortTIME COMPLETED:
11:45 AM
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Licensing Program Analysts (LPA) Jey Cardenas made an announced visit, and met with the Applicant Nisha Fort to conduct a Pre-Licensing evaluation. An application was received by Community Care Licensing Department (CCLD) on 02/22/2021 for an initial application to serve elderly ages 60 years and over. Approved capacity is for five (5) ambulatory residents, zero (0) non-ambulatory residents, and zero (0) bedridden residents.

Structure: Facility is a one-story family home with three (3) bedrooms (bedroom #2 and #3 are shared), (2) full bathrooms, living room/ dining area, and kitchen. A car port / shaded area is located on the front of the property; LPA observed one (1) bench to be used for resident seating. Total of two (2) exits; main exit located in living room, exit two is in bedroom #1. Front yard landscape is in good condition at time of visit. A locked closet/storage space located across from bedroom#3 is used for extra linens, towels, cleaning supplies and hygiene supplies. Washer/Dryer appliances are located in the kitchen. There are no firearms in the home. Bedroom: Bedrooms are equipped with one bed per resident, night-stand, chair, and overhead lightning. Bathrooms: bathrooms have a working toilet, wash basin, tub/shower. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, fitted sheet, blanket and bedspreads. One fully charged fire extinguisher is located near the kitchen. Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in kitchen drawer inaccessible and under lock. Smoke Detectors/Carbon Monoxide(s): Facility is equipped with operational dual/ hardwired smoke detectors and carbon monoxide Appliances: Stove burners (gas), oven, microwave, and washer/dryer are in working condition. There is one working (1) refrigerator in the home and working cordless telephone is located in the Livingroom. Toxins: Cleaning supplies and toxins are stored and locked in kitchen sink cabinet. Water Temperature: Hot water was tested in bathroom #2; temperature was 116 Degrees F. Medication, First-Aid Kit & Book: Designated centrally stored medication area was locked and located in a standing cabinet space located in the Livingroom. Sufficient bandages and one (1) tweezer. Facility has First Aid Kit,
SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2021
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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME: FORT FAITH RCFE
FACILITY NUMBER: 198320191
VISIT DATE: 07/13/2021
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kit Manual thermometer and scissors. Residents & Staff Files: Designated area for files are located in a locked standing cabinet in Livingroom. Applicant will handle cash resources of residents and keep residents cash resources in the facility under lock. Pools/Jacuzzi & Pets: No bodies of water and no pets on these premises. Fire Clearance: Fire clearance was approved on 06/08/2021. Required postings are posted where residents and staff can view.

Component III was completed with applicant, applicant understood licensing requirements and agrees.

During the pre-licensing inspection certain items were observed which do not comply with applicable laws and regulations; By the end of the visit the licensee indicated they shall modify or repair the following items by 7/16/21 and submit to the CCLD office to the attention of LPA Cardenas. If additional time is required to complete noted items to correct, then the applicant will request an extension in writing prior to the due date. Some items may require a follow up inspection for verification of correction.

1. Provide LPA with fire extinguisher purchase receipt.
2. Provide outside patio seating for total of five residents.
3. Adequate seating sufficient for five residents in dinning room.
4. Have First Aid/ CPR book
5. Ensure bathrooms have no-slip mats/strips
6. Submit complete Mitigation Plan to LPA
7. Grab bars in bathroom located inside bedroom#1.



LPA reminded applicant the following items shall be posted always: Emergency numbers, Personal rights, Emergency Disaster Plan, Complaint Procedures, and facility sketch show emergency exits.

An exit interview was conducted and a copy of this report has been furnished to the applicant. Accordingly, LPAs will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.
SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2021
LIC809 (FAS) - (06/04)
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