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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603664
Report Date: 09/17/2022
Date Signed: 09/17/2022 04:02:03 PM


Document Has Been Signed on 09/17/2022 04:02 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
MONTEREY PARK, CA 91754



FACILITY NAME:PATRICIA'S ELDER CAREFACILITY NUMBER:
197603664
ADMINISTRATOR:BRITO, PATRICIAFACILITY TYPE:
740
ADDRESS:2446 W. 234TH ST.TELEPHONE:
(310) 530-8946
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY:6CENSUS: 6DATE:
09/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:ERLINDA BASALLOTIME COMPLETED:
04:00 PM
NARRATIVE
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On 9/17/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced annual required visit. Upon arrival, LPA Montoya called the Administrator and the Licensee twice but no answer. LPA left messages but no reply. LPA proceeded to the facility's front door and asked Staff Erlinda Bassalo who opened the door. LPA conducted a risk assessment and based on Staff Bassalo's response, the facility is clear of Covid-19 infection. LPA explained the purpose of today’s visit. Staff Bassalo assisted LPA with the visit.

This facility consists of a kitchen, dining area, four (4) resident bedrooms, one (1) bedroom for awake staff (bedroom#3), three (3) bathrooms (one bathroom is in bedroom#1 and bedroom#4 & #5 shared bathroom), indoor patio, garage (washer/dryer located in garage).

LPA toured the single-story facility with Staff Erlinda Bassalo. LPA observed 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 resident 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. The water temperature measured at 101.1 degree Fahrenheit in the bathroom located in the hallway near bedrooms #1, #2 and #3. The water temperature in the bathroom between resident bedrooms #4 and #5 measured at 100.2 degree Fahrenheit. A comfortable temperature was maintained in the facility.



LPA observed the facility to be appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food supplies. The facility has (2) fire extinguisher that was charged and last serviced on 7/3/2022, smoke detectors, and carbon monoxide were operable. The facility conducted a Fire/Safety Drill on 9/8/2022. A working telephone (310) 530-8946 remains available.

Evaluation Report Continues on LIC 809-C
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2022
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


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: PATRICIA'S ELDER CARE
FACILITY NUMBER: 197603664
VISIT DATE: 09/17/2022
NARRATIVE
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for residents, staff and visitors, and sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has an approved Mitigation Plan Report on file with CCLD.

Technical Assistance Advisory Issued.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. Appeal rights and a copy of this report was provided to Staff Erlinda Bassalo.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/17/2022 04:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: PATRICIA'S ELDER CARE
FACILITY NUMBER: 197603664

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2022

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 observation and interview, the licensee did not comply with the section cited above. LPA Montoya observed water temperature in the bathroom between resident bedrooms #4 and #5 was measured at 100.2 degree Fahrenheit. And the temperature of water in the bathroom near bedrooms #1, #2 and #3 bedrooms was measured at 101.2 degree Fahrenheit. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2022
Plan of Correction
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Licensee shall adjust the water temperature to 105-120 degree Fahrenheit. Licensee shall test the water temperature every two hours for 24 hours and shall submit the recorded water temperature to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date 9/18/2022.
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 AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 09/17/2022 04:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: PATRICIA'S ELDER CARE
FACILITY NUMBER: 197603664

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2022

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 observation and interview, the licensee did not comply with the section cited above. LPA observed the garage is cluttered. LPA observed and took photos of the boxes, clothes, black plastic bags, old furniture, old oxygen tanks, fruits, wheelchairs, bed frames, large water containers, empty jars on the floor, white plastic bags full of empty water bottles, etc. LPA also observed clutters on the left outdoor passageway of the home. LPA observed a mattress and an old door leaning on the wall, empty buckets, a microvawe and a tv on the ground, etc. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2022
Plan of Correction
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Licensee agreed to clean up and organize the garage and the passageway. Licensee shall submit a POC to CCLD via email to lourdes.montoya@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: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4