198320304-8-16-2022-11-AS-PSCT-CHCT8G-20220816143020

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320304
Report Date: 08/16/2022
Date Signed: 08/16/2022 02:30:40 PM

Document Has Been Signed on 08/16/2022 02:30 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:	KINAH MAE HOME LLC		FACILITY NUMBER:	198320304
ADMINISTRATOR:	WHITFORD, WALKIRIA		FACILITY TYPE:	740
ADDRESS:	1420 W. 186TH ST.		TELEPHONE:	(310) 720-7080
CITY:	GARDENA	STATE: CA	ZIP CODE:	90248
CAPACITY: 6		CENSUS: 6	DATE:	08/16/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Walkiria Whitfield/Renette Dela Cruz		TIME COMPLETED:	02:40 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 08/16/22, Licensing Program Analyst (LPA) Perry Scott/LPM Janae Hammond conducted an announced visit to this facility for the purpose of pre-licensing. We were greeted by administrator Walkiria Whitford and Renette Dela Cruz (Licensee) and explained the purpose of today’s pre-licensing inspection visit. An application was submitted to CCLD on 05/13/22 in the initial license application for a Residential Facility for the Elderly, ages 60 years and above. The applicant requested a capacity of six (6) individuals, of which may be five (5) non-ambulatory, and one (1) bedridden. Structure: The home is a four (4) bedroom, two (2) bathroom, one-story home with a one car garage situated in a residential neighborhood. The home includes a living, dining, kitchen, and laundry area. The living room has a fireplace. The living area included recliners, couches, and a table. The kitchen has a refrigerator and stove. The rear exterior is fenced throughout. The passageways, walkways, and steps are free from obstructions. Bedrooms Residents: The facility has four (4) bedrooms for residents. Bedroom #1 is approved for two (2) non-ambulatories. Bedroom # 2 is approved for one (1) bedridden. Bedroom # 3 is approved for two (2) non-ambulatories. And bedroom # 4 is approved for one (1) non-ambulatory resident. All rooms include a full- or twin-sized beds, at least one (1) chair, nightstands, and table lamps. All bedrooms are equipped with a ceiling light. All rooms had a dresser/storage area, which complies with the requirement of 8 cubic feet of space. All rooms had closets for ample storage. Evaluation Report Continues

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: KINAH MAE HOME LLC	FACILITY NUMBER: 198320304
	VISIT DATE: 08/16/2022

NARRATIVE

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Bedrooms Staff:
There is not a bedroom designated for live-in staff.

Bathrooms:
The home has two (2) bathrooms. Bathrooms are adjacent to each bedroom. All bathrooms have a working toilet, washbasin, and shower with grab bars and non-skid mats.

Linens & Hygiene Supplies:
Beds have the required linen supplies which include, pillowcases, mattress pads, fitted sheets, blankets, and bedspreads. An adequate supply of linen is stored in the hall closet.

Emergency Phone Numbers, Exit Plan & Menu:
Emergency phone numbers are posted. The exit plan and menu are posted and readily available for review. There are three (3) fire extinguishers located in the kitchen, garage, hallway. A telephone line is available in the living room area. Emergency supplies and Personal Protective Equipment supplies are stored in the storage area in the facility. The applicant submitted a Mitigation Plan on 06/03/22.
Food Service:
Dishes, cups, and flatware are stored in the kitchen cabinets, inspected, and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in a locked drawer. Food supply is adequately stored in kitchen cabinets and consists of boxed and can goods. The kitchen counters also had small appliances.
Smoke Detectors:
Smoke and carbon monoxide detectors are throughout the interior space.
Toxins:
All toxins are locked and stored under the kitchen sink cabinet and in the garage.

Evaluation Report Continues

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: KINAH MAE HOME LLC	FACILITY NUMBER: 198320304
	VISIT DATE: 08/16/2022

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Stove burners, oven, microwave, washer, and dryer are working. There is one (1) refrigerator in the home. The home is equipped with central heaters and air conditioning systems.
Water Temperature:
The water temperature is 114.8 degrees throughout the kitchen and bathrooms.
Medications, First-Aid Kit & Book:
A first aid kit is stored in the facility with a first aid manual. It was inspected and has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze, and current first aid manual locked and inaccessible to residents. The client's medications will be stored in a cabinet locked in the dining area and inaccessible.
Resident & Staff Files:
The applicant is not handling the cash resources for residents. Records of staff and residents will be stored in a locked cabinet in the dining area.
Reading Material, Games, Equipment & Materials:
The facility has board games, books, magazines, and other recreational materials for the resident's use all stored in the living room.
Pool/Jacuzzi & Pets:
There are no pets, jacuzzi, or bodies of water on the property.
Fire clearance:
A Fire Clearance inspection was conducted on 07/21/22 approved for a capacity for five (5) non-ambulatory, and one (1) bedridden.
Component III:
LPA Scott/LPM Hammond conducted the Pre-Licensing inspection along with the information provided about how to operate the facility within substantial compliance with Component III PowerPoint.

LPA observed no deficiencies that needed to be corrected during this pre-licensing inspection.

An exit interview was conducted, and a copy of this report has been furnished to the administrator, Walkiria Whitford and Renette Dela Cruz. LPA Scott 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.
END OF REPORT

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022

LIC809 (FAS) - (06/04)

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