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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602872
Report Date: 11/24/2021
Date Signed: 11/24/2021 03:27:27 PM

Document Has Been Signed on 11/24/2021 03:27 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
MONTERY PARK, CA 91754
FACILITY NAME:GREAT PLACE HOME CAREFACILITY NUMBER:
198602872
ADMINISTRATOR:SARMIENTO, BERNADETTEFACILITY TYPE:
740
ADDRESS:1556 238TH STREETTELEPHONE:
(310) 891-3349
CITY:HARBOR CITYSTATE: CAZIP CODE:
90710
CAPACITY: 6CENSUS: 6DATE:
11/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Naumati Iosefo-Lead Caregiver TIME COMPLETED:
03:35 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
On 11/24/2021, Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with staff Naumati Iosefo-Lead Caregiver and explained the purpose of today’s visit. The facility is an RCFE licensed for five (5) non- ambulatory clients and one (1) bedridden.

The facility is a one-story structure located in a residential neighborhood. It consists of the following: Five (5) bedrooms, including one (1) staff bedroom, two (2) full bathrooms, living room, dining room, and kitchen. A closet/storage space is located in the hallway. A two (2) car attached garage is located in the front of the property and a backyard with shaded area and seating area with table.

LPA and staff toured the physical plant. There were no bodies of water or obstructions on the premises. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client 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.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Cleaning supplies, toxins and sharps objects are stored in locked kitchen drawers/cabinets locked and not accessible to clients. The kitchen was inspected and there is a 2-day supply of perishable and a 7-day supply of non-perishable food available, maintained properly. Fully charged fire extinguisher was found in kitchen.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocol for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, all mandated inspection control posters were posted.

Deficiencies cited on case management.

Advisories are on attached 9102

An exit interview was conducted, and a copy of this report was provided to Naumati Iosefo, lead staff.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE: DATE: 11/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/24/2021
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 4