198320366-5-4-2023-11-AS-AINZ-CRHPZH-20230504114533

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320366
Report Date: 05/04/2023
Date Signed: 05/04/2023 11:45:42 AM

Document Has Been Signed on 05/04/2023 11:45 AM - 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:	FAMILY FIRST BOARD & CARE		FACILITY NUMBER:	198320366
ADMINISTRATOR:	FAMISAN, ROSEMARIE		FACILITY TYPE:	740
ADDRESS:	14532 HALLDALE AVE		TELEPHONE:	(310) 910-6142
CITY:	GARDENA	STATE: CA	ZIP CODE:	90247
CAPACITY: 6		CENSUS: 6	DATE:	05/04/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:07 AM
MET WITH:	Rosemarie Famisan/Licensee		TIME COMPLETED:	11:45 AM

NARRATIVE

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On 5/4/23 at 9:10 AM Licensing Program Manager (LPM)/ Eva Alvarez and Licensing Program Analysts (LPA)/Alfonso Iniguez conducted a pre-licensing evaluation Change of Ownership (CHOW) for an RCFE (Adult Residential Care Facility for the Elderly) facility type. Today’s pre-licensing evaluation was conducted with Rosemarie Famisan/Administrator/Licensee.

The licensee has applied for a license to serve (6) 60 years and over. The fire clearance is approved for (3) non-ambulatory and (1) bedridden. Approved hospice waiver for (6) Hospice Residents.

LPM and LPA toured facility Kitchen, Dining Room, Living Room, (4) Bedrooms, (2) Bathrooms, Garage, Back Yard, and Patio with shaded area. LPM and LPA observed sufficient storage areas for kitchen supplies, linens, medications (secured) and chemicals (secured).

LPM and LPA observed the following during this visit:

MEDICATIONS

There is a locked centralized storage area for Resident medications.

PHYSICAL PLANT

LPM and LPA observed the facility is clean, sanitary, and in good repair. Protective devices are in place. Indoor and outdoor passageways, stairways, open porches, and other areas of potential hazard are free of obstructions. All window screens are clean and in good repair. Facility temperature is between 68°F. degrees and 85°F. degrees. Open porch, and areas of potential hazard are well-lit and equipped with sturdy hand railings. Carbon monoxide/Smoke detectors operate properly.

Evaluation Report continues LIC 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

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: FAMILY FIRST BOARD & CARE	FACILITY NUMBER: 198320366
	VISIT DATE: 05/04/2023

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BEDROOMS

No client bedroom is a passageway to another room, bath, or toilet. There is a bed for each client with a mattress, mattress pad, bedsprings, and pillow(s) which are clean and in good repair.

There is dresser and closet space for each client that includes at least two (2) drawers of dresser space per client. There is a chair and lamp for each client and at least one (1) night stand per two (2) clients.

BATHROOMS

There is at least (2) toilets and washbasins per six (6) clients, family, and personnel. There is at least one (2) shower per ten (10) clients, family, and personnel. Hot water temperature is between 105°F.-120°F. degrees Fahrenheit. Bathrooms are located near client bedrooms. Facility has enough night-lights in all hallways.

SUPPLIES

There are client personal hygiene supplies to include soap, toothpaste, toilet paper. There is a sufficient supply of clean linens to permit weekly changing or more of client top sheets, bottom sheets, bedspreads, blankets, pillowcases, mattress covers, bath towels, hand towels, and washcloths.

FOOD SERVICE

Dining room is near kitchen. Refrigerator and freezer are clean and have the capacity to store at least two (2) days of perishable foods. There is storage for seven (7) day supply of non-perishable food. There are enough tableware, tables, dishes, and utensils. All equipment, dishes, and utensils are clean and well maintained. All kitchen, food storage, and preparation areas are clean.

RECORDS

There is confidential storage for personnel records at the facility. There is storage for Resident confidential information and records at the facility.

Evaluation Report continues LIC 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

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: FAMILY FIRST BOARD & CARE	FACILITY NUMBER: 198320366
	VISIT DATE: 05/04/2023

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ADMINISTRATION

The emergency exiting plan and emergency phone numbers are posted. Client Personal Rights are posted. Posting both sides of the Personal Rights form LIC 613 meets this requirement. Facility Visiting Policy is posted. Licensing Complaint Poster is posted. There is space available for resident council meetings and resident council postings.

ACTIVITIES

There is an indoor activity space. There is at least one common room available to clients for visitors. There are activity supplies to include board games located in the living room.

MISCELLANEOUS

There are first-aid supplies to include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual. There is space and equipment for laundry. There is a space for clean linen storage and a separate space for soiled linen. There is an operating telephone available to clients. Emergency lighting and supplies to include flashlights with batteries.

LPM and LPA observed a sign-in/sanitation station at the facility entry. There is hand sanitizer located at the entrance of the facility. Facility has screening process for all visitors, sanitizer/soap and paper towels.

During today’s inspection LPA found the following correction is required:

Currently Garage has been converted into living space and occupied by staff member.

Correction needed:

Licensee will ensure the garage is utilized according to facility sketch.

LPA will inform CAB regarding today's visit

Exit interview conducted with Rosemarie Famisan/Administrator-Licensee.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

LIC809 (FAS) - (06/04)

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