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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603664
Report Date: 10/03/2023
Date Signed: 10/03/2023 02:33:09 PM


Document Has Been Signed on 10/03/2023 02:33 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:BRITO, PATRICIAFACILITY TYPE:
740
ADDRESS:2446 W. 234TH ST.TELEPHONE:
(310) 530-8946
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY:6CENSUS: 5DATE:
10/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:57 AM
MET WITH:David GenerTIME COMPLETED:
02:45 PM
NARRATIVE
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On 10/03/2023 at 8:58 AM, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced Required – Annual Inspection and met with David Gener, Administrator/Caregiver. Five (5) residents and two (2) staff were present during this inspection.

Facility is licensed to serve six (6) non-ambulatory residents. The facility also has an approved dementia waiver. The facility currently has 5 non-ambulatory residents. The Annual Licensing Fees are current.

The home consists of 1 floor level with: 4 resident rooms, 3 bathrooms, 1 staff room, kitchen, dining room, living room, and garage.

The administrator accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards.

Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no weapons on the premises.

Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and shower was free of mold/mildew. Hot water temperature properly measured at 113.3F in shower and 116F in kitchen.

Common areas were clear of hazards, doorways were free of obstructions.

LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxics were kept in locked storage cabinet. First Aid kit was available. One fire extinguisher, last serviced June 15, 2023 was observed in the kitchen area. LPA tested carbon monoxide detectors and smoke detectors. Both devices were functional.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023
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 8


Document Has Been Signed on 10/03/2023 02:33 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks.  Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.  A report shall be made of each screening, signed by the examining physician.  The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health.  Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

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 1 out of 5 staff members which poses a potential health risk to persons in care.
POC Due Date: 10/23/2023
Plan of Correction
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4
Administrator will email LIC 503 Health Screening with TB restults for S4 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 CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/03/2023 02:33 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

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 in 1 out of 5 residents which poses a potential health and safety risk to persons in care.
POC Due Date: 10/23/2023
Plan of Correction
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Administrator will email a medical assessment, signed by a physician, made within the last year for R3 to regina.cloyd@dss.ca.gov. See LIC858.
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.

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 in 1out of 5 residents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2023
Plan of Correction
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Administrator will email an examination for TB for R2 to regina.cloyd@dss.ca.gov. See LIC858.
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 CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023
LIC809 (FAS) - (06/04)
Page: 3 of 8


Document Has Been Signed on 10/03/2023 02:33 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2023

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 for LPA observed an insect in the kitchen near the window by the table. In addition, insects were observed in the living room area, which poses potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2023
Plan of Correction
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Administrator will provide proof of correction that the facility is free of rodents, vermin, and insects. Proof of correction shall be emailed to regina.cloyd@dss.ca.gov by the POC Due Date.
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: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023
LIC809 (FAS) - (06/04)
Page: 4 of 8


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: 10/03/2023
NARRATIVE
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5 staff records were reviewed and had required criminal record clearances or criminal record exemptions. See LIC 859 for details. 2 staff members were interviewed.

5 resident records were reviewed. See LIC 858 for details. 2 residents were interviewed.

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

An exit interview was conducted, Plans of Corrections were reviewed and developed with the Administrator. A copy of this report and appeal rights were discussed and left with David Gener.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
LIC809 (FAS) - (06/04)
Page: 8 of 8