197604374-4-12-2023-11-AS-DESA-CQTTLS-20230412145000

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197604374
Report Date: 04/12/2023
Date Signed: 04/12/2023 02:50:09 PM

Document Has Been Signed on 04/12/2023 02:50 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:	AYRES RESIDENTIAL CARE HOME		FACILITY NUMBER:	197604374
ADMINISTRATOR:	ANTANINA REMEIKIENE		FACILITY TYPE:	740
ADDRESS:	10862 WELLWORTH AVE		TELEPHONE:	(310) 475-6484
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90024
CAPACITY:	6	CENSUS: 6	DATE:	04/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:10 AM
MET WITH:	MICHAEL GABAI		TIME COMPLETED:	02:48 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 04/12/2023, Licensing Program Analyst (LPA) David Espana conducted an unannounced annual required visit with a primary focus on CARE Inspection Tool. LPA met with Administrator Michael Gabai, Lucy Uman and explained the purpose of today’s visit. The facility is licensed to operate for six (6) residents of which six (6) non-ambulatory elderly residents ages 60 and above. The facility is approved for three (3) hospice. The facility is a single-story structure located in a residential neighborhood. It consists of the following: six (6) resident's bedrooms with all six having their individual bathroom and one bathroom (7 total number of bathrooms), 1 office room, 1 living area, 1 dining area, 2 closets, 2 entrance gates observed adjacent from sidewalk, 2 six foot wood doors that give entrance to the back-side-yard were also observed, 1 kitchen, surrounding property fencing (rear and both sides of the property), 3 toilets operable/observed, 2 showers operable/observed, a total of 16 window screens were observed, 1 fireplace in the living room, 1 laundry area room in hallway and 1 outside shaded rear patio area. LPA and administrator toured the physical plant. 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 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 meets the Title 22 regulations in the kitchen and bathrooms. A comfortable temperature of 73 was maintained in the facility.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

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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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: AYRES RESIDENTIAL CARE HOME	FACILITY NUMBER: 197604374
	VISIT DATE: 04/12/2023

NARRATIVE

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LPA observed the facility to be sanitary and 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 available maintained properly. Two (2) fire extinguishers were fully charged with annual maintenance of 09/24/2022 (one in the end of the hallway by exit door between bedroom 5 and master bedroom & with one in the kitchen area). 11 Smoke detectors and 1 carbon monoxide in kitchen entrance were operable. A review of 5 Medication Administration Records (MAR) was maintained in order and accurate.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, 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.

Deficiencies were cited during this inspection visit, both were Type b Technical Assistance.

An exit interview was conducted, and a copy of this report was provided to Administrator Michael Gabai.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/12/2023 02:50 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: AYRES RESIDENTIAL CARE HOME	FACILITY NUMBER: 197604374
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/12/2023

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
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above. Based on record review, interview and observation, at around 11:30 AM, LPA Espana observed S4's CPR certificate was expired. Administrator stated S4 will bring up to date first aid certificate, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/12/2023
	Plan of Correction
1 2 3 4	Licensee willadhere to Title 22 and ensure CPR certificate is on file and current and provide proof to CCLD. Proof of correction to be sent to CCLD/El Segundo ASC office by POC date of 05/12/2023.

Type B

Section Cited

CCR

87412(a)(12)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) Hazardous health conditions documents as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation,interview, record review, the licensee did not comply with the section cited above. Based on LPA staff record review (S1, S2, & S3) and interview with the Administrator, there was no evidence of a health screen LIC 503, however, TB test forms were provided by the physician, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/12/2023
	Plan of Correction
1 2 3 4	Licensee willadhere to Title 22 and ensure health screen LIC 503 is on file and current and provide proof to CCLD. Proof of correction to be sent to CCLD/El Segundo ASC office by POC date of 05/12/2023 david.espana@dss.ca.gov.

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	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

LIC809 (FAS) - (06/04)

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