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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603247
Report Date: 10/30/2024
Date Signed: 10/31/2024 02:21:13 PM

Document Has Been Signed on 10/31/2024 02:21 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:EVERLASTING HOME CAREFACILITY NUMBER:
198603247
ADMINISTRATOR/
DIRECTOR:
BULLER, KATHRINAFACILITY TYPE:
740
ADDRESS:5413 BROCKWOOD STREETTELEPHONE:
(562) 421-4855
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY: 6CENSUS: 6DATE:
10/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:10 PM
MET WITH:Indu Amarasinghe, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 10/30/2024 at 12:10 PM, Licensing Program Analyst (LPA) Zina Brown conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the one- year inspection. LPA met with Indu Amarasinghe, Administrator and the purpose of the visit was discussed. Facility is licensed to serve 6 non- ambulatory residents. Three (4) residents are diagnosed with dementia, (1) home health, (2) hospice care and (0) palliative care services. The facility does not handle any of the residents’ money.

The home is a single story home consisting of: (4) resident bedrooms, (1) full bathroom, 1 staff bathroom, den, living room, kitchen with dining area, laundry room (located in the attached garage) and an outdoor shaded patio area. LPA toured the resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. The resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured at 116.9 F - 124.7 F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions.

LPA conducted a records review of (6) client records and (6) staff records reviewed the facility disaster plan. All client & Staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (6) Client Medication Administration Records and did not observed any discrepancies at the time of visit.

Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly, and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

During todays visit LPA did not observe any deficiencies. An exit interview was conducted with Indu Amarasinghe.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024
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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