198320429-8-5-2024-11-AS-EDAT-D7UMLS-20240805094249

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320429
Report Date: 08/01/2024
Date Signed: 08/05/2024 09:44:24 AM

Document Has Been Signed on 08/05/2024 09:44 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	ETHEL'S GUEST HOME		FACILITY NUMBER:	198320429
ADMINISTRATOR/ DIRECTOR:	MONTERROSO, ETHEL JANE		FACILITY TYPE:	740
ADDRESS:	1730 W 1ST STREET		TELEPHONE:	(310) 634-7522
CITY:	SAN PEDRO	STATE: CA	ZIP CODE:	90732
CAPACITY: 6		CENSUS: 6	DATE:	08/01/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:56 AM
MET WITH:	Ethel Monterroso		TIME VISIT/ INSPECTION COMPLETED:	01:27 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 08/01/24, Licensing Program Analysts (LPAs) Ernand Dabuet and Zina Brown conducted announced visit to this home. LPA was greeted by applicant Ethel Monterroso and explained the purpose of today’s pre-licensing inspection visit. An application was submitted to CCLD on 04/24/24 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 maybe five (5) non-ambulatory, and one (1) bedridden. Structure: The home is a four (4) bedroom, two (2) bathroom, one story home with a two (2) car garage situated in a residential neighborhood. The home includes a living, dining, kitchen, and laundry area. The living room did include a fireplace. The living area included seating. 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 had four (4) bedrooms for residents. There are four (4) bedrooms for non-ambulatory residents and (1) of the bedrooms specific for the bedridden. All rooms include a twin-size bed, one (1) chair, one (1) night stand, and one (1) table lamp. All bedrooms are equipped with a ceiling light. All rooms had a dresser, which complies with the requirement of 8 cubic feet of space. All rooms had closets for ample storage. The room also included wall night lights. Evaluation Report Continues

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024

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: ETHEL'S GUEST HOME	FACILITY NUMBER: 198320429
	VISIT DATE: 08/01/2024

NARRATIVE

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Bedrooms Staff:
There is no bedroom designated for live-in staff.

Bathrooms:
The home has two (2) bathrooms. One (1) staff bathroom. Bathrooms are accessible in all rooms. 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 inside the bedrooms.

Emergency Phone Numbers, Exit Plan & Menu:
Emergency phone numbers. The exit plan and menu are posted and readily available for review throughout the home. There are two (2) fire extinguishers located in the kitchen and entry way. A telephone line is available in the kitchen and living room. Emergency supplies and Personal Protective Equipment supplies are stored in the garage. The applicant as an approved Infection Control Plan on file.

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 kitchen drawer. Food supply is adequately stored in kitchen cabinets and consists of the can goods. The kitchen counters also had small appliances.

Smoke Detectors:
Smoke and carbon monoxide detectors throughout the interior space. Hardwired smoke detectors in all four (4) bedrooms and hallways. Carbon monoxide is combined with smoke detectors.

Toxins:
All toxins are locked and stored under the kitchen sink cabinet.

Evaluation Report Continues

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024

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: ETHEL'S GUEST HOME	FACILITY NUMBER: 198320429
	VISIT DATE: 08/01/2024

NARRATIVE

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Appliances:
Stove burners, oven, microwave, washer, and dryer are working. The kitchen counters also had small appliances which includes a, blender, toaster, and coffee maker. There is one (1) refrigerator in the home. The refrigerator measured a temperature of at least 40 degrees Fahrenheit for appropriate food storage. The home is equipped with with central heating and air.

Water Temperature:
The water temperature is 119.4 degrees throughout the kitchen and bathrooms.

Medications, First-Aid Kit & Book:
A first aid kit is stored in the kitchen cabinet which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze, and current first aid manual locked and inaccessible to residents. The resident's medications will be stored in the same kitchen cabinet locked in the kitchen area and inaccessible to residents.

Resident & Staff Files:
The applicant is not handling the cash resources for residents. Records of staff and residents are stored in a locked kitchen cabinet.

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 pool in the fenced area.

Evaluation Report Continues

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: ETHEL'S GUEST HOME	FACILITY NUMBER: 198320429
	VISIT DATE: 08/01/2024

NARRATIVE

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Fire clearance:
A Fire Clearance inspection was conducted on 12/14/23 approved for a capacity for five (5) non-ambulatory, one (0) for ambulatory, and one (1) for bedridden.

Component III:
LPA Brown conducted the Pre-Licensing inspection along with the information provided about how to operate the facility within substantial compliance with Component III PowerPoint.

LPAs Dabuet and Brown observed the following corrections:

Bathroom #1 screen need to be replaced or repaired.
Kitchen Dishwasher is non-operable.- Corrected 08/24/24
Range stove hood requires deep cleaning. - Corrected 08/04/24
Staff Bed need to be removed from the garage. - Corrected 08/04/24
Soffit light over the kitchen sink need to be cleaned. - Corrected 08/04/24

An exit interview was conducted, and a copy of this report has been furnished to the applicant Ethel Monterroso. LPA Dabuet 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: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024

LIC809 (FAS) - (06/04)

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