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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603664
Report Date: 11/22/2024
Date Signed: 11/22/2024 01:26:55 PM

Document Has Been Signed on 11/22/2024 01:26 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:PATRICIA'S ELDER CAREFACILITY NUMBER:
197603664
ADMINISTRATOR/
DIRECTOR:		BRITO, PATRICIAFACILITY TYPE:
740
ADDRESS:2446 W. 234TH ST.TELEPHONE:
(310) 530-8946
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 6CENSUS: 4DATE:
11/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:23 AM
MET WITH:Erlinda BasalloTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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On 11/22/24, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced required – annual inspection and met with Staff Erlinda Basallo. LPA spoke with Licensee Patricia Brito over the phone. Facility is licensed to serve six (6) non-ambulatory residents. It also has an approved dementia waiver. The home consists of one floor level with: four resident rooms, three bathrooms, one staff room, kitchen, dining room, living room, and garage.

Staff accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed.

Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises. 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. 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 toured the kitchen area. First Aid kit was available. One fire extinguisher, last serviced June 19, 2024 was observed in the kitchen area. Continue to LIC809-C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2024
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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Document Has Been Signed on 11/22/2024 01:26 PM - It Cannot Be Edited


Created By: Regina Cloyd On 11/22/2024 at 09:22 AM
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: PATRICIA'S ELDER CARE
FACILITY NUMBER: 197603664

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2024

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…

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above for room #1 which poses a potential safety risk to persons in care. LPA observed a blue tarp on the ceiling in room #1. Staff explained that some ceiling work needed to be completed due rain.
POC Due Date: 12/10/2024
Plan of Correction
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4
The Licensee will provide evidence of correction to regina.cloyd@dss.ca.gov by the POC due date.

Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
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:Ulysses Coronel
LICENSING EVALUATOR NAME:Regina Cloyd
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/22/2024 01:26 PM - It Cannot Be Edited


Created By: Regina Cloyd On 11/22/2024 at 12:13 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: PATRICIA'S ELDER CARE
FACILITY NUMBER: 197603664

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above for four out of five staff members which poses a potential health and safety risk to persons in care. LPA did not observe active CRP cards for S1 - S4.
POC Due Date: 12/10/2024
Plan of Correction
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The Licensee will email evidence of correction to regina.cloyd@dss.ca.gov by the POC due date.
Type B
Section Cited
CCR
87412(d)
Personnel Records
(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements.

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 which poses a potential safety or personal rights risk to persons in care. LPA did not observe an active or pending renewal RCFE certification for S1 and S2.
POC Due Date: 12/10/2024
Plan of Correction
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The Licensee will provide proof of correction to regina.cloyd@dss.ca.gov by the POC due date.
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:Ulysses Coronel
LICENSING EVALUATOR NAME:Regina Cloyd
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/22/2024 01:26 PM - It Cannot Be Edited


Created By: Regina Cloyd On 11/22/2024 at 12:13 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: PATRICIA'S ELDER CARE
FACILITY NUMBER: 197603664

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. While sitting at the kitchen table, LPA observed two small roaches on the table and one large roach near the kitchen window. LPA also observed small flies on the table and cork board.
POC Due Date: 12/10/2024
Plan of Correction
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The licensee will email a preventative pest control plan, specifying the frequency and duration of treatment/services, to regina.cloyd@dss.ca.gov by the POC due date.
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above for R3 which poses a potential personal rights risk to persons in care. LPA observed full bed rails without a doctor's order for R3.
POC Due Date: 12/10/2024
Plan of Correction
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The Licensee will email doctor's orders for R3's full bed rails by the POC due date.
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:Ulysses Coronel
LICENSING EVALUATOR NAME:Regina Cloyd
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/22/2024 01:26 PM - It Cannot Be Edited


Created By: Regina Cloyd On 11/22/2024 at 12:13 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: PATRICIA'S ELDER CARE
FACILITY NUMBER: 197603664

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87625(b)(8)
Managed Incontinence
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (8) Privacy shall be afforded when care is provided.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above for R3 and R4 which poses a potential personal rights risk to persons in care. During the facility tour, LPA observed staff changing R3 without a privacy screen in front of R4. Staff informed LPA that the privacy screen was on the patio.
POC Due Date: 12/10/2024
Plan of Correction
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The Licensee will provide a plan ensuring residents will be afforded privacy during toileting and showering. Plan to be emailed to regina.cloyd@dss.ca.gov by the POC due date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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:Ulysses Coronel
LICENSING EVALUATOR NAME:Regina Cloyd
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2024


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: PATRICIA'S ELDER CARE
FACILITY NUMBER: 197603664
VISIT DATE: 11/22/2024
NARRATIVE
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Staff tested the carbon monoxide detector and smoke detectors in the house. Both devices were functional.

Five staff records were reviewed, five out of five staff records had required criminal record clearances or criminal record exemptions.
Four resident records were reviewed and, four out of four resident records had medical assessments. Two residents’ medication was reviewed.

Deficiencies are being cited based on LPA’s observation and record review in accordance with the California Code of Regulations, Title 22, see LIC809D..

  1. During the facility tour, LPA observed a blue tarped on the ceiling in Room #1. Staff explained that some ceiling work needed to be completed due rain.
  2. During the facility tour, LPA observed full bed rails without a doctor's order for R3.
  3. During the facility tour, LPA observed staff changing R3 without a privacy screen in front of R4. Staff informed LPA that the privacy screen was on the patio.
  4. LPA observed two small roaches on the table and one large roach near the kitchen window. LPA also observed small flies on the table and cork board in the kitchen.
  5. During record review, LPA did not observe active CRP cards for S1 - S4.
  6. During record review, LPA did not observe an active or pending renewal RCFE certification for S1 and S2.

An exit interview was conducted and technical assistance was provided to Staff Erlinda Basallo. A copy of this report and appeal rights were discussed and left with Basallo.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC809 (FAS) - (06/04)
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