<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603664
Report Date: 11/01/2024
Date Signed: 11/01/2024 01:11:39 PM

Document Has Been Signed on 11/01/2024 01:11 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:
11/01/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:39 PM
MET WITH:Caregiver Paciencia DasallaTIME VISIT/
INSPECTION COMPLETED:
01:25 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11/01/24, Licensing Program Analyst (LPA) Regina Cloyd make an unannounced visit to the facility listed above. The purpose of the visit was explained to the Caregiver Paciencia Dasalla and the Licensee over the phone. The LPA came to complete the facility's annual inspection but the Administrator was not on site and staff could not locate resident nor staff files. Interview with the Licensee indicated that the Administrator has been away from the facility for about a week due to an emergency.

Deficiencies are being cited (LIC809-D).

An exit interview was conducted, plans of correction developed, and a copy of this report with the appeal rights was provided to Caregiver Paciencia Dasalla.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2024
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 11/01/2024 01:11 PM - It Cannot Be Edited


Created By: Regina Cloyd On 11/01/2024 at 12:57 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: 11/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/12/2024
Section Cited
CCR
87413(a)(1)

1
2
3
4
5
6
7
87413 Personnel - Operations (a) In each facility: (1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks.

This requirement is not met as evidence by:
1
2
3
4
5
6
7
The Licensee will develop a plan of correction and email it to regina.cloyd@dss.ca.gov by the POC due date.
8
9
10
11
12
13
14
Based on LPA's observation and interview, the Administrator has been away from the facility for about a week and the caregiver could not locate staff nor residents' files which poses a potential safety risks to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 11/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2