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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602012
Report Date: 09/08/2022
Date Signed: 09/08/2022 02:13:48 PM

Document Has Been Signed on 09/08/2022 02:13 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:C&H #7 RESIDENTIAL CARE FOR ELDERLYFACILITY NUMBER:
198602012
ADMINISTRATOR:ASHLEY ADLEANFACILITY TYPE:
740
ADDRESS:4702 EAST SAN VINCENTE STREETTELEPHONE:
(562) 630-8123
CITY:COMPTONSTATE: CAZIP CODE:
90221
CAPACITY: 4CENSUS: 3DATE:
09/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:01 AM
MET WITH:Glenda Moreno House ManagerTIME COMPLETED:
02:17 PM
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Licensing Program Analyst (LPA) Jeremiah Randle conducted an unannounced Annual required and infection control visit to the above facility. LPA was met by Glenda Moreno House Manager. (3) residents are ambulatory . The facility is a single-story structure located in a residential neighborhood. It consists (3) bedrooms, (1) full bathrooms, and 1/2 bath, shaded back yard, front yard, laundry room and a detached 2 garage.

LPA and Glenda Moreno toured the entire facility inside and out. Documents are posted as mandated. Bedrooms 2-3 are occupied by residents and contain the mandated furniture, bedroom 1 is occupied by staff. The bathrooms are clean and operational. First aid kit is fully stocked with manual, smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to residents. Three Residents files are current as well as Medication Record. Staff file of the House Manager is current. Ample supply of perishable and nonperishable food per Title 22, hot water temperature is 115 degrees Fahrenheit, linens and personal hygiene supplies are adequate, sharp items are inaccessible to residents’ however hazardous toxin dish detergent was left out on the counter in the kitchen, 1 fire extinguishers were fully charged. First Aid kit complete and with Manual. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in good repair. During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry, visitors are logged, and temperature checked, sanitizer/soap in the staff bathroom and additional sanitation supplies are locked in the garage. LPA observed staff and residents wearing masks, resident private rooms will be converted to isolation rooms (if needed) and required postings throughout the facility. The resident’s temperatures are checked and logged once a day. PPE's are enough for 30 days.According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued a citation noted on 809 D. An exit interview was conducted with Rebekah Jefferson Lead Staff and report provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jeremiah Randle
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2022
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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Document Has Been Signed on 09/08/2022 02:13 PM - It Cannot Be Edited


Created By: Jeremiah Randle On 09/08/2022 at 12:48 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: C&H #7 RESIDENTIAL CARE FOR ELDERLY
FACILITY NUMBER: 198602012

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/09/2022
Plan of Correction
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House Manager removed detergent and placed in locked cabinet.
LPA observed House Manager Clear POC at the time of visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Janae Hammond
LICENSING EVALUATOR NAME:Jeremiah Randle
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2022


LIC809 (FAS) - (06/04)
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