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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191600461
Report Date: 03/15/2023
Date Signed: 03/15/2023 04:01:18 PM

Document Has Been Signed on 03/15/2023 04:01 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:ADULT DEVELOPMENT CENTER - HERMOSA BEACHFACILITY NUMBER:
191600461
ADMINISTRATOR:LEUCI, MARYFACILITY TYPE:
775
ADDRESS:710 PIER AVE.TELEPHONE:
(310) 318-9343
CITY:HERMOSA BEACHSTATE: CAZIP CODE:
90254
CAPACITY: 52CENSUS: 16DATE:
03/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:06 PM
MET WITH:Vince Ivory-AdministratorTIME COMPLETED:
03:00 PM
NARRATIVE
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On 3/15/23 LPA Alfonso Iniguez made an unannounced visit to the program. The purpose of today's visit was to conduct an unannounced annual inspection of the program. On today's visit LPA met with facility Vince Ivory/Manager. The facility profile shows that the facility is licensed for a capacity of 52 clients (8 non-ambulatory and 44 ambulatories). The program administrator stated that the program has 16 clients enrolled in the program. The staff to client ratio is 1 staff to 4 clients. Administrator stated that the program has 0 clients with a Restricted Health Care condition. Currently, there are 0 clients using protective devices. The program conducted a fire drill in December 2022 and a Disaster Plan was on file. The last inspection held by the fire department was in December 2022. The program does not provide transportation.

As a part of today's inspection LPA reviewed 5 client records, 5 staff records, medications and inspected the entire facility inside and out. LPA and administrator toured the entire facility. The property consists of main office, conference room, kitchen(repair), 2 activity classroom, computer room, and 2 bathrooms are available for use by clients/staff that are part of the community center.

The facility program is through Harbor Regional Center clients. LPA and administrator toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. The tour consisted of the following: kitchen area (in repair), 2 activity classrooms, 2 bathrooms, computer room, gym, and outside areas. The activity rooms had plenty of storage space and client chairs. The kitchen is in repair now. Cleaning supplies were locked. All the rooms that were inspected were clean. Activity rooms had 2 first aid kits and 2 fire extinguisher that were fully charge. Smoke detectors and carbon monoxide were working. Walls and floors were in good repair. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured in bathroom #1 111.8° F and bathroom #2 112.2° F. A comfortable temperature is maintained in the facility.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE: DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/15/2023
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 5
Document Has Been Signed on 03/15/2023 04:01 PM - It Cannot Be Edited


Created By: Alfonso Iniguez On 03/15/2023 at 03:08 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: ADULT DEVELOPMENT CENTER - HERMOSA BEACH
FACILITY NUMBER: 191600461

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82068.2(f)(1)(B)
Needs and Services Plan
(f) The completed Needs and Services Plan shall include: (1) The client's desires and background and formal supports, obtained from the client's family or his/her authorized representative, if any, regarding the following: (B) A written medical assessment including primary physician, health problems and medical history, prescribed medications and their strength, quantity, frequency required and purpose as specified in Section 82069(b)(3).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above LPA during records review did not find a medical assesment on C#1 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/30/2023
Plan of Correction
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Program director will get the physicians assessment for C#1 and submit proof to LPA due date via fax
Type B
Section Cited
CCR
82069(a)
Client Medical Assessments
(a) Prior to or within 30 calendar days following the acceptance of a client, the licensee shall obtain a written medical assessment of the client that determines the licensee's ability to provide necessary health-related services to the client. The assessment shall be used in developing the Needs and Services Plan.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above LPA during records review did not find a medical assesment on C#1 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/30/2023
Plan of Correction
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Program director will get the physicians assessment for C#1 and submit proof to LPA due date via fax
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2023


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 03/15/2023 04:01 PM - It Cannot Be Edited


Created By: Alfonso Iniguez On 03/15/2023 at 03:08 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: ADULT DEVELOPMENT CENTER - HERMOSA BEACH
FACILITY NUMBER: 191600461

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82069(b)(1)
Client Medical Assessments
(b) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above LPA during records review did not find a medical assesment on C#1,C#2 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/30/2023
Plan of Correction
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Program director will get TB tests for C#1, C#2 and submit proof to LPA due date via fax
Type B
Section Cited
CCR
82070(a)
Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client. A separate, complete, and current record shall be maintained at the program site for each client.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above LPA during records review did not find a medical assesment on C#1,C#2,C#3 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/30/2023
Plan of Correction
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Program Director will ensure all clients records will be updated and submit proof to LPA via fax or email
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/15/2023 04:01 PM - It Cannot Be Edited


Created By: Alfonso Iniguez On 03/15/2023 at 03:08 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: ADULT DEVELOPMENT CENTER - HERMOSA BEACH
FACILITY NUMBER: 191600461

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82072(a)
Personal Rights
(a) Each client shall have personal rights which include, but are not limited to, the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above LPA during records review did not find LIC 613 personal rights on C#1,C#2 which poses a potential health, safety or personal rights risk to persons in care
POC Due Date: 03/30/2023
Plan of Correction
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Program director will get LIC 613-personal rights for C#1, C#2 and submit proof to LPA due date via fax
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
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: ADULT DEVELOPMENT CENTER - HERMOSA BEACH
FACILITY NUMBER: 191600461
VISIT DATE: 03/15/2023
NARRATIVE
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Deficiencies Cited Under California Code of Regulations Title 22

Exit interview conducted and a copy of the appeal rights were given to administrator

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5