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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602924
Report Date: 01/19/2023
Date Signed: 01/19/2023 03:20:36 PM

Document Has Been Signed on 01/19/2023 03:20 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:RICH RESIDENTIAL CARE LLC 2FACILITY NUMBER:
198602924
ADMINISTRATOR:RICHARDSON, GENTRYFACILITY TYPE:
740
ADDRESS:2030 W. 94TH PLACETELEPHONE:
(310) 350-1123
CITY:LOS ANGELESSTATE: CAZIP CODE:
90047
CAPACITY: 4CENSUS: 4DATE:
01/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:19 PM
MET WITH:Gentry Richardson - Licensee/AdminTIME COMPLETED:
03:50 PM
NARRATIVE
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01/19/23, Licensing Program Analyst (LPA) Mario Leon conducted an unannounced annual required visit with a primary focus on Infection Control measures. LPA Leon met with the Administrator Gentry Richardson and LPA Leon explained the purpose of today’s visit. The facility is licensed to operate four (4) ambulatory Seniors ages 60 and above. Currently, four clients reside at this facility.

The facility is a one-story structure located in a residential neighborhood. It consists of the following: three (3) bedrooms (three client bedrooms), one (1) staff office room (non-staff bedroom), two (2) bathrooms, living area, dining area, kitchen, outside area with table, umbrella, and chairs. LPA Leon 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 client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be clean and operational. The water temperature measured above Title 22 regulations at 143.6 F in kitchen and 140.3 F in bathroom one (1).

Storage areas for personal hygiene, toxins, and sharp objects were stored and not accessible to clients. Bleach and cleaning solution was located under the sink in bathroom two (2). The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly. Two fire extinguishers were charged, smoke detectors and carbon monoxide detectors were operable.

During the visit, LPA Leon observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA Leon observed staff were wearing face coverings. LPA observed the facility has at least a 30-day supply of Personal Protective Equipment (PPE), stored in detached garage . All mandated infection control posters were present throughout the facility. A review of staff and resident temperature logs were reviewed. The facility has a Mitigation Plan Report approved by CCLD on file. See LIC809-C
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2023
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: RICH RESIDENTIAL CARE LLC 2
FACILITY NUMBER: 198602924
VISIT DATE: 01/19/2023
NARRATIVE
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LPA advised the Licensee, Gentry Richardson, to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

During today’s visit there were three (3) deficiencies observed, see LIC809-D.

During today's visit there was one Technical Violation observed, see LIC9102.

Exit interview held. A copy of the report was provided to Licensee Gentry Richardson

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 01/19/2023 03:20 PM - It Cannot Be Edited


Created By: Mario Leon On 01/19/2023 at 02:49 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: RICH RESIDENTIAL CARE LLC 2
FACILITY NUMBER: 198602924

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Leon's observation, the licensee did not comply with the section cited above in which the water temperature was above Title 22 regulations, measured at 141 F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/23/2023
Plan of Correction
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LPA Leon and Licensee Gentry Richardson have agreed that Licensee will submit media (video) evidence of the change of water temperature that falls within Title 22 regulations (105 F-120 F) prior to the POC due date via email to assigned LPA at Pamela.Bunker@DSS.CA.GOV and/or today's inspector, LPA Leon, at Mario.Leon@DSS.CA.GOV.
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: 01/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 01/19/2023 03:20 PM - It Cannot Be Edited


Created By: Mario Leon On 01/19/2023 at 02:49 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: RICH RESIDENTIAL CARE LLC 2
FACILITY NUMBER: 198602924

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Leon's observation, the licensee did not comply with the section cited above in which the rear door with ramp does not open without obstruction which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2023
Plan of Correction
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LPA Leon and Licensee Gentry Richardson have agreed that Licensee will submit media (video) evidence of the repair of awning located above rear door attached to resident room (bedroom #3) prior to the POC due date via email to assigned LPA at Pamela.Bunker@DSS.CA.GOV and/or today's inspector, LPA Leon, at Mario.Leon@DSS.CA.GOV.
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: 01/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 01/19/2023 03:20 PM - It Cannot Be Edited


Created By: Mario Leon On 01/19/2023 at 03:09 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: RICH RESIDENTIAL CARE LLC 2
FACILITY NUMBER: 198602924

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2023

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 LPA Leon's observation, the licensee did not comply with the section cited above in the fact that there was a bottle of bleach located below bathroom two (2) sink which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/19/2023
Plan of Correction
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Licensee Gentry Richardson immediately removed the cleaning solutions and placed them in a locked closet, inaccessible to clients.
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: 01/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023


LIC809 (FAS) - (06/04)
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