198320425-6-13-2024-11-AS-JCAN-D67REN-20240613125748

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320425
Report Date: 06/13/2024
Date Signed: 06/13/2024 12:57:55 PM

Document Has Been Signed on 06/13/2024 12:57 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	MONTOAK ONE		FACILITY NUMBER:	198320425
ADMINISTRATOR/ DIRECTOR:	SHAHEEN, NAJMA		FACILITY TYPE:	740
ADDRESS:	1811 255TH STREET		TELEPHONE:	(310) 906-7713
CITY:	LOMITA	STATE: CA	ZIP CODE:	90717
CAPACITY: 6		CENSUS: 4	DATE:	06/13/2024
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:20 AM
MET WITH:	NAJMA SHAHEEN		TIME VISIT/ INSPECTION COMPLETED:	02:00 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 06/13/2024 at 10:20 AM, Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced Post licensee inspection visit at the Montoak One Facility. LPA Calderon was allowed entry into the facility by Administrator Najma Shaheen. Administrator Najma Shaheen asked infection control questions and took LPA Calderon temperature prior to entrance into the facility. The licensee has applied for a license to serve (6) elderly residents ages 59 and older. Currently, there are (4) residents residing in the facility age 59 or older. LPA Calderon explained to Administrator Najma Shaheen, the purpose of the Post licensee Inspection visit, and escorted LPA Calderon on a tour of the entire inside and outside facility grounds. As part of the inspection, LPA Calderon reviewed: (4) resident service records (reviewed personnel policies, abuse reporting procedures and in-service training and medication procedures for 4 residents), (4) resident medication records, (3) staff records, and inspected the inside facility and outside grounds. The facilities’ last fire drill was conducted on 05/01/2024. The one-story residential home consists of (5) resident bedrooms, (2) resident bathrooms, living room, kitchen, attached garage with washer and dryer/ storage area, backyard with NO table and chairs were noted. No weapons are stored in the premises. Kitchen was inspected and observed to be clean and operational. A two-day supply perishable and seven-day supply of non-perishable foods are present in the facility. Emergency Water supply is found in the bedrooms.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024

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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: MONTOAK ONE	FACILITY NUMBER: 198320425
	VISIT DATE: 06/13/2024

NARRATIVE

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LPA Calderon observed that all facility rooms are clean and in good repair. A comfortable temperature was observed, and the facility has central air and heating. LPA Calderon observed the following during inspection of resident’s rooms: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, LPA Calderon observed fully stocked closet with bedding, towels, and toiletries supplies. Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. LPA Calderon observed bathrooms were found to be within Title 22 regulation. Bathroom #1 hot water temperature properly measured at 105 degrees Fahrenheit, and bathroom #2 hot water temperature properly measured at 108 degrees Fahrenheit. Kitchen hot water temperature properly measured at 115 degrees Fahrenheit. Facility (1) carbon Monoxide and (7) Smoke Detectors hard wired and connected were tested and are working properly. The facility (1) Fire Extinguishers were checked and found to be fully charged and accessible. All exit doors in the facility have alarm systems. All toxins and knifes are locked/secured and inaccessible to residents. Medications are centrally stored and in a locked storage cabinet. Facility first aid kit is fully stocked with manual was checked and in order. Outside grounds were toured and no bodies of water were observed. All Exits/ Walkways around the home were free of debris and hazards. Outside patio accessible to residents. Three (4) resident files were reviewed and found to be complete. LPA Calderon reviewed (4) resident medications and they were all found to be administered according to doctor's orders. Three (3) staff files were checked and have the required documents. LPA Calderon noted the Administrator Najma Shaheen Certification # 6043760740 expiration date of 04/12/2025 was valid at time of visit. The facility does NOT handle resident's money/cash resources and a Surety bond is not needed currently. All the required documents are posted in the facility in a clearly visible area to include a copy of the General Liability policy James River Insurance Company #001519280 which was valid policy at time of inspection (01/30/2024 to 01/30/2025. LIC500 all 3 staff members are associated to the facility. LPA Calderon requested a copy of the LIC308 dated 03/18/2024, designate name Najma Shaheen.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024

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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: MONTOAK ONE	FACILITY NUMBER: 198320425
	VISIT DATE: 06/13/2024

NARRATIVE

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During the visit, LPA Calderon observed the physical plant & environment safety practices. LPA Calderon observed the facility has a thirty-day supply of Personal Protective Equipment (PPE).

LPA Calderon advised the Administrator Najma Shaheen to continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA Calderon did not observe NO deficiencies therefore NO citations were issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Administrator Najma Shaheen.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024

LIC809 (FAS) - (06/04)

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