<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601828
Report Date: 05/11/2021
Date Signed: 05/12/2021 12:03:19 PM

Document Has Been Signed on 05/12/2021 12:03 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:BUCKINGHAM PLACEFACILITY NUMBER:
198601828
ADMINISTRATOR:NAQUITA MEADOWSFACILITY TYPE:
740
ADDRESS:4108 W. 59TH PLACETELEPHONE:
(213) 361-2792
CITY:LOS ANGELESSTATE: CAZIP CODE:
90043
CAPACITY: 6CENSUS: 3DATE:
05/11/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Caregiver, Shaneyce WalkerTIME COMPLETED:
12:35 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
Licensing Program Manager (LPM) Angela Kendrick and Licensing Program Analyst (LPA) Troy Agard conducted an unannounced annual inspection. LPA Agard meet with Caregiver, Shaneyce Walker. LPA Agard informed caregiver the purpose of today’s visit is to conduct the facility’s annual inspection, review the physical plant, medication, food service, and infectious control measures.

The facility is a single-story, 2-bedroom, 2-bathroom home located in a residential neighborhood. The facility has a living room, dining room, kitchen, den, laundry area, shaded outdoor area. Bedrooms #1 and 2 are designated as resident bedrooms. Facility is licensed for 2 non ambulatory and serves individuals with Developmental Disabilities. Facility has an adequate amount of food.

During the tours the following deficiencies were observed:
LPA Agard observed knives and detergent unlocked in kitchen cabinet assessable to clients in care.
LPA Agard observed medication unlocked that was not on Medication Administration Records.

Deficiencies cited Under California Code of Regulations, Title 22, Division 6, Chapter 8. Exit interview conducted and copy of appeal rights were given at the time of the visit.
SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Troy Agard
LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 05/12/2021 12:03 PM - It Cannot Be Edited


Created By: Troy Agard On 05/11/2021 at 12:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BUCKINGHAM PLACE
FACILITY NUMBER: 198601828

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)


This requirement is not met as evidenced by: 87465 (h)(2) medication The following requirements shall apply to medications which are centrally stored: (2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.. LPA Agard observed knives and detergent unlocked in kitchen cabinet assessable to clients in care.
Deficient Practice Statement
1
2
3
4
Based on observation the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2021
Plan of Correction
1
2
3
4
Facility will enusre that all detergents and knives are locked at all times. Facility will provide training to all staff and provide proof of training to LPA Agard.
Type A
Section Cited
CCR
87309(a)(1)


This requirement is not met as evidenced by:87309 (a) (1) Storage space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
(1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. LPA Agard observed medication unlocked that was not on Medication Administration Records.
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2021
Plan of Correction
1
2
3
4
Facility will ensure medication is centerally stored, locked and inaccessible to clients in care. Facility Admin / Licensee will provide photographic proof on installation of lock.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Angela J Kendrick
LICENSING EVALUATOR NAME:Troy Agard
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2021


LIC809 (FAS) - (06/04)
Page: 2 of 2