Facility Evaluation Report

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was screened and met by Jamila Neal, Direct Service Professional II (DSP II) and Reginald Roy, Direct Service Professional II (DSP II) and explained the purpose of the visit. LPA spoke with the Executive Director, Tamara Frisby on the phone and had advised LPA that someone will be at the facility to access files. At 12:18pm, Asst. Administrator Kendall D. Edwards arrived and assisted LPA with the inspection. Shortly after, Shawn Bailey, Licensee arrived. The facility is licensed to serve for (4) Developmentally Disabled Adults, ages 18 through 59, (3) clients may be non ambulatory . There was one (1) clien t present at the facility during the visit, and the other three (3) clients were at the Day Program. All clients residing at this facility receive case management services provided by South Central LA Regional Center .

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station and PPE supplies located near the front door. T he facility has not submitted the required Infection Control Plan. Facility has COVID-19 signage posted throu ghout the facility. Bathrooms have hand washing signs, soap and paper towels. Staff are adhering to infection control requirements.

Physical Plant/Environment Safety: The facility is a single storey home located in a residential neighborhood, contains a total of four (4) client bedrooms, two (2) full bathrooms, half (1/2) bathroom, a living room/activity area, kitchen, dining area, backyard, and attached garage. Currently, there are four (4) clients living in the facility. According to the Licensee, the facility is considered a Community Placement Project (CPP). The interior and exterior physical plant was inspected. Client bedrooms were toured. Each bedroom has a smo ke detector, bed, linen, dresser, light, chair and sufficient closet space. Bathrooms have non-skid materials and contained hygiene supplies including liquid soap, paper towels, and toilet paper. Exit doors are free of any obstruction and there are no pools or large bodies of water. Backyard was inspected and there was a sitting area, but did not have a shaded area as the patio umbrella was broken. LPA observed torn window screen on bathroom #3. Attached garage was inspected and there is an extra refrigerator/freezer to stock up additional food items. Kitchen knives, sharps objects, cleaning supplies and toxic substances are locked and inaccessible to clients. LPA observed that the cleaning supplies were stored and mixed with the food supplies in the attached garage. There is a fire extinguisher observed to be fully charged and was last serviced on July 12, 2023. Smoke alarms and carbon monoxide were operable. There are no firearms or weapons stored at the facility. Water temperature readings are not within the required 105 - 120 degrees Fahrenheit. Hot water supply measured 121.6 deg F in bathroom #1, 127.7 in bathroom #2, and 125.7 in bathroom #3.

Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has not been added to the Plan. A fire clearance for (4) clients is in place. Liability Insurance policy in the amount of $1,000,000.00 each occurrence and #3,000,000.00 in general aggregate is valid and will expire on 2/28/2024 . Surety Bond is in effect and in force with bond amount of $5000. Last Fire Drill was conducted on 8/18/2023.