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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603664
Report Date: 04/18/2023
Date Signed: 04/18/2023 04:01:47 PM


Document Has Been Signed on 04/18/2023 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: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: 3DATE:
04/18/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:DAVID GENERTIME COMPLETED:
04:00 PM
NARRATIVE
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On 04/18/2023, Licensing Program Analyst (LPA) Lourdes Montoya conducted a case management - deficiency visit at this facility. LPA was greeted by Administrator David Gener. LPA explained the purpose of the visit. LPA observed two staff and six residents present during the visit.

During an unrelated visit, LPA observed the following deficiencies:

1. Kitchen and garage are cluttered, the kitchen floor is filthy.
2. Scissors and a knife on the kitchen counter accessible to residents.
3. Three hand rakes in the backyard accessible to residents.

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 Administrator David Gener.

SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2023
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 2


Document Has Been Signed on 04/18/2023 04:01 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/19/2023
Section Cited

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(f) The following shall be stored inaccessible to residents with dementia:
(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement was not met as evidenced by:
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Administrator moved the scissors, knife and hand rakes to a locked drawer. This was corrected during the visit.
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During LPAs visit, LPA observed a pair of scissors and a knife on the kitchen counter accessible to residents. LPA also observed three hand rakes in the backyard accessible to residents. This poses an immediate health, safety and/or personal rights risk to residents with dementia
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Type B
04/24/2023
Section Cited

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87303 Maintenance and Operation
(a) 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 was not met as evidenced by:
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Administrator shall clean and organize the kitchen and the garage. Administrator shall submit a POC to CCLD via email to lourdes.montoya@dss.ca.gov
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LPA observed the kitchen and the garage are cluttered, the kitchen floor is filthy. This poses a potential health, safety and/or personal rights risk to residents in care.
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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: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2