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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602263
Report Date: 12/02/2022
Date Signed: 12/02/2022 12:55:18 PM

Document Has Been Signed on 12/02/2022 12:55 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:NP CARE HOMEFACILITY NUMBER:
198602263
ADMINISTRATOR:TATUM, RONICFACILITY TYPE:
740
ADDRESS:3767 VIRGINIA ROADTELEPHONE:
(323) 205-5145
CITY:LOS ANGELESSTATE: CAZIP CODE:
90016
CAPACITY: 6CENSUS: 6DATE:
12/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:56 AM
MET WITH:Ronic Tatum and Krystal Perkins - AdministratorsTIME COMPLETED:
01:30 PM
NARRATIVE
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On 12/02/22, Licensing Program Analyst (LPA) Mario Leon conducted an unannounced annual required visit with a primary focus on Infection Control measures and the purpose of today's visit has been explained. LPA met with administrator Ronic Tatum and explained the purpose of today’s visit. The facility is licensed to operate for six (6) non-ambulatory of which one (1) may be bedridden of elderly residents ages 60 and above. The facility is approved for two (2) hospice residents.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident's rooms, two (2) common bathrooms, living area, dining area, kitchen, outside covered patio area, and a laundry. A garage is being used for storage and office space.

LPA and administrator toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 119.8 F in bathroom number two (2). A comfortable temperature was maintained in the facility.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored, yet accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available, maintained properly. A fire extinguisher was charged, smoke detectors and carbon monoxide were operable. The facility has a working landline telephone and the last fire drill was conducted on 11/27/22.

See LIC 809-C
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE: DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2022
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 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: NP CARE HOME
FACILITY NUMBER: 198602263
VISIT DATE: 12/02/2022
NARRATIVE
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff residents were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff Fit Testing is maintained and accurate. The facility has an approved Mitigation Plan Report with CCLD.

There were two (2) deficiencies cited during this inspection visit, see LIC809-D. There were technical assistance notes provided, see LIC9102.

An exit interview was conducted and a copy of this report was provided to Krystal Perkins.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 12/02/2022 12:55 PM - It Cannot Be Edited


Created By: Mario Leon On 12/02/2022 at 12:27 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: NP CARE HOME
FACILITY NUMBER: 198602263

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(k)
Criminal Record Clearance
(k) The licensee shall maintain documentation of criminal record clearances or criminal record exemptions of volunteers that require fingerprinting and non-client adults residing in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on Licensing Program Analyst Mario Leon, one volunteer required to be present in the facility did not have any personnel record relating to criminal clearance, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care
POC Due Date: 02/01/2023
Plan of Correction
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Administrator Krystal Perkins has agreed to have the volunteer, Mrs. Lorna Tomlinson (V1), fingerprinted and cleared for any criminal association prior to continuing V1's presence at this facility by submitting documentation, through email, in order to clear this deficiency
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:Ulysses Coronel
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2022


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 12/02/2022 12:55 PM - It Cannot Be Edited


Created By: Mario Leon On 12/02/2022 at 12:27 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: NP CARE HOME
FACILITY NUMBER: 198602263

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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 Licensing Program Analyst Mario Leon, Three (3) out of four (4) locks required to remove accessibility to cleaning solutions were inoperable, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2022
Plan of Correction
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Administrator Ronic Tatum has agreed to repair all locks, whether the hazardous objects are present or not, by submitting documentation, through email, in order to clear this deficiency.
Type B
Section Cited
CCR
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on Licensing Program Analyst Mario Leon, Three (3) out of four (4) locks required to remove accessibility to cleaning solutions were inoperable, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2022
Plan of Correction
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Administrator Ronic Tatum has agreed to repair all locks, whether the hazardous objects are present or not, by submitting documentation, through email, in order to clear this deficiency.
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:Ulysses Coronel
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2022


LIC809 (FAS) - (06/04)
Page: 4 of 6