198320490-3-6-2025-11-AS-JANO-DEHVTW-20250306154348

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320490
Report Date: 03/06/2025
Date Signed: 03/06/2025 03:44:22 PM

Document Has Been Signed on 03/06/2025 03:44 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:	CARRIE'S LOVING CARE		FACILITY NUMBER:	198320490
ADMINISTRATOR/ DIRECTOR:	HARTMAN, PRINCEY		FACILITY TYPE:	740
ADDRESS:	935 W 127TH STREET		TELEPHONE:	(424) 456-5270
CITY:	COMPTON	STATE: CA	ZIP CODE:	90222
CAPACITY: 4		CENSUS: 0	DATE:	03/06/2025
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:31 AM
MET WITH:	Princey Hartman		TIME VISIT/ INSPECTION COMPLETED:	04:00 PM

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On 03/06/2025 the Licensing Program Manager Ulysses Coronel & Licensing Program Analyst Jose Anguiano conducted an announced visit to the facility for purpose of a pre-licensing evaluation. The pre-licensing evaluation was conducted with Princey Hartman.

On 04/22/2024 an application was submitted to CCLD, for a Residential Care Facility for the Elderly. The requested capacity is for Resident ages 60 and over of which 4 may be non-ambulatory. And waiver granted for 4 Hospice. The facility is a 3-bedroom, 2 bathroom, 1 story house.

CCLD staff conducted a review of the Physical Plant, Bedrooms, Bathrooms, Supplies, Food Service, Medications, Records, Administration, Activities, Pe-Licensing Checklist and Component III Orientation.

MEDICATIONS

There is a locked centralized storage area for client medications.

PHYSICAL PLANT

Facility is clean, sanitary, and in good repair. Protective devices are in place to include nonslip material on rugs. Indoor and outdoor passageways, stairways, 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. Fire Alarms and Smoke alarms operate properly. Carbon monoxide detectors operate properly.

BEDROOMS

Halls, stairways, unfinished attics or basements, garages, storage areas, and sheds, or similar detached buildings 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

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Jose Anguiano
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025

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: CARRIE'S LOVING CARE	FACILITY NUMBER: 198320490
	VISIT DATE: 03/06/2025

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equipment. 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. 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 for each client and at least one (1) nightstand per two (2) clients. If applicable, resident bedrooms with security bars on windows/doors have at least one (1) window/door in the bedroom with an approved safety release to allow emergency evacuation.

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. Hot water temperature is between 105-120 degrees Fahrenheit. Bathroom is located near client bedrooms.

SUPPLIES

There are client personal hygiene supplies to include feminine napkins, soap, toothpaste, toilet paper, and comb. 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(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. Refrigerator is a maximum of 45 degrees Fahrenheit. A seven (7) day supply of non-perishable food is present. The kitchen, all equipment, dishes, utensils, food storage, and preparation areas are clean are in good repair.

RECORDS

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

ADMINISTRATION

The emergency exiting plan and emergency phone numbers are posted. Client Personal Rights are posted.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Jose Anguiano
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025

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: CARRIE'S LOVING CARE	FACILITY NUMBER: 198320490
	VISIT DATE: 03/06/2025

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Posting both sides of the Personal Rights form LIC 613 meets this requirement. Facility Visiting Policy is posted. There is space available for resident council meetings and resident council postings.

ACTIVITIES

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 material.

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. Vehicles used to transport clients are in safe operating condition.

PRE-LICENSING CHECKLIST

Completed by licensee and reviewed by LPA.

COMPONENT III

Provided via video conference, information was provided about how to operate the facility within substantial compliance.

During the pre-licensing inspection certain items were observed which do not comply with applicable laws and regulations; the following items must be corrected, and proof of correction shall be submitted to the CCLD office to the attention of LPA by xx/xx/xx17. If additional time is required to complete noted items to correct, then the applicant will request an extension in writing prior to the due date. Some items may require a follow up inspection for verification of correction.

1. Fireplace is accessible to clients.

2. Stairways, inclines, ramps, need sturdy hand railings.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Jose Anguiano
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025

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: CARRIE'S LOVING CARE	FACILITY NUMBER: 198320490
	VISIT DATE: 03/06/2025

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3. Lamps are not available for residents in bedrooms.

4. Night-light in the hallways outside non-private bathrooms.

5. Licensing Complaint Poster (20 X26 inches) and Long Term Care Ombudsman contact information needs to be posted on wall.

6. Grass in the backyard needs to be trimmed to avoid tripping hazard.

7. The power outlet in bathroom #1 does not have a cover plate.

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: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Jose Anguiano
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025

LIC809 (FAS) - (06/04)

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