198320400-9-20-2023-11-AS-LMOA-CVV4AM-20230920185609

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320400
Report Date: 09/20/2023
Date Signed: 09/20/2023 06:56:16 PM

Document Has Been Signed on 09/20/2023 06:56 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	A FAMILY HOMECARE		FACILITY NUMBER:	198320400
ADMINISTRATOR:	MABUTAS, RHODA		FACILITY TYPE:	740
ADDRESS:	23612 PRESIDENT AVE		TELEPHONE:	(424) 378-1218
CITY:	HARBOR CITY	STATE: CA	ZIP CODE:	90710
CAPACITY: 6		CENSUS: 0	DATE:	09/20/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	RHODA MABUTAS		TIME COMPLETED:	04:30 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 9/20/2023 AT 10:30 AM, Licensing Program Analyst (LPA) Lourdes Montoya conducted an announced pre-licensing evaluation. Today’s pre-licensing evaluation was conducted with applicant Rhoda Mabutas, administrator. On 6/5/2023, an application was submitted to Community Care Licensing Division (CCLD), for Initial license for a Residential Care Facility for the Elderly. The requested capacity is for six (6) residents of which five (5) may be non-ambulatory and one (1) may be bedridden. The facility consists of four (4) resident bedrooms, 1 staff room, 2 bathrooms, a kitchen, a living and dining area, an enclosed patio, outdoor patio (front and back) and a garage. LPA conducted a review of the Physical Plant, Bedrooms, Bathrooms, Supplies, Food Service, Medications, Records, Administration, Activities, Pe-Licensing Checklist and Component III Orientation. PHYSICAL PLANT The facility is clean, sanitary, and in good repair. Indoor and outdoor passageways, inclines, ramps, 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 degrees and 85 degrees F. Ramps, open porches, and areas of potential hazard are well-lit and equipped with sturdy hand railings. BEDROOMS Halls, storage areas, are not being used as client bedrooms. Client bedrooms are large enough to allow for easy passage and to accommodate furniture and assistive devices such as wheelchairs, walkers, or oxygen equipment. REPORT CONTINUED IN LIC 809C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: A FAMILY HOMECARE	FACILITY NUMBER: 198320400
	VISIT DATE: 09/20/2023

NARRATIVE

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No client bedroom is a passageway to another room, bath or toilet. There is a bed for each client with a mattress, mattress pad, bedspring, and pillow(s) which are clean and in good repair. Mattresses and pillows are flame-retardant. There is dresser and closet space for each client that includes at least two (2) drawers or eight (8) cubic feet of dresser space per client. There is a chair and lamp for each client. LPA did not observe any nightstand in all four (4) resident bedrooms.

BATHROOMS

There is at least one (1) toilet and washbasin per six (6) clients, family, and personnel. There is at least one (1) shower or bathtub per ten (10) clients, family, and personnel. The hot water temperature is between 105-120 degrees Fahrenheit. The bathroom is located near client bedrooms. There are night lights in the hallways outside non-private bathrooms.

SUPPLIES

Personal hygiene supplies for residents were observed. 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

The dining room is near kitchen. Refrigerator(s) and freezer(s) are clean and large enough for the storage of at least two (2) days of perishable foods. Freezer is 0 degrees Fahrenheit or less. Refrigerator is a maximum of 45 degrees Fahrenheit. A seven (7) day supply of non-perishable food is present. There is sufficient amount of tableware, tables, dishes, and utensils. There is sufficient amount of equipment for the storage, preparation, and service of food. All equipment, dishes, and utensils are clean and well maintained. All kitchen, food storage, and preparation areas are clean.

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. Licensing Complaint Poster is posted. There is space available for resident council meetings and resident council postings. Facility Visiting Policy was not observed.

REPORT CONTINUED IN LIC 809C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: A FAMILY HOMECARE	FACILITY NUMBER: 198320400
	VISIT DATE: 09/20/2023

NARRATIVE

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ACTIVITIES

There is an outdoor activity space with a shaded area and furnished for outdoor use. There is at least one common room available to clients for visitors. There are activity supplies to include newspapers, magazines, and a variety of reading materials.

RECORDS

There is confidential storage of personnel records at the facility. There is confidential storage of client records at the facility.

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 a designated laundry space. There is an operating telephone available to clients. Emergency lighting and supplies to include flashlights with batteries.

PRE-LICENSING CHECKLIST: Completed by licensee and reviewed by LPA.

COMPONENT III orientation was conducted with the applicant, Rhoda Mabutas (administrator).

During the pre-licensing inspection, there were items that were observed which do not comply with applicable laws and regulations:
Facility Visiting policy was not observed in the plan of operation and no Visiting Policy was posted. LPA did not observe any nightstand in all four (4) resident bedrooms.

An exit interview was conducted, and a hard copy of this report has been furnished to the applicant.

Accordingly, LPA 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 the applicant.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

LIC809 (FAS) - (06/04)

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