197607231-8-29-2024-11-AS-SLEO-D8LRW4-20240829132232

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607231
Report Date: 08/29/2024
Date Signed: 08/29/2024 01:22:59 PM

Document Has Been Signed on 08/29/2024 01:22 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:	A HELPING HAND SOUTH BAY		FACILITY NUMBER:	197607231
ADMINISTRATOR:	SUSAN COOPER		FACILITY TYPE:	740
ADDRESS:	4848 134TH PL.		TELEPHONE:	(310) 973-1315
CITY:	HAWTHORNE	STATE: CA	ZIP CODE:	90250
CAPACITY:	6	CENSUS: 5	DATE:	08/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Administratory - Sohayl Zoughi		TIME COMPLETED:	02:00 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 08/29/2024 at around 8:00 AM, Licensing Program Analyst (LPA) Leandro conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with Administrator, Sohayl Zoughi. LPA explained the purpose of the visit and was accompanied by staff inside and outside the facility during this inspection. This facility is licensed to serve 6 non-ambulatory adults ages 60 and above, of which 2 may be bedridden, and 3 may be on hospice. A total of 5 residents are currently residing in this facility. The facility has an outstanding balance of $495 of Annual Licensing Fees due on 09/26/2024. LPA provided pin to Administrator and informed him that the licensee can pay their annual licensing fees in the CCLD website.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024

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 09/23/2024 11:23 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 09/20/2024 12:45 PM

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: A HELPING HAND SOUTH BAY	FACILITY NUMBER: 197607231
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(d)(3)

Incidental Medical and Dental Care Services

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in not having date and time the PRN medications were taken for residents in care, which poses a potential health and safety risk to persons in care.
	POC Due Date: 09/17/2024
	Plan of Correction
1 2 3 4	The Licensee will create a plan to follow CCR87465(d)(3) and retrain staff. Licensee will email proof of correction to Socorro.Leandro@dss.ca.gov.

Type B

Section Cited

CCR

87705(c)(5)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out 5 residents not having their updated Medical Assessment and Reappraisal, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/01/2024
	Plan of Correction
1 2 3 4	Licensee will update Resident 5's Medical Assessment & Reappraisal. Licensee will create a plan to ensure that residents with dementia/alzheimer’s have a yearly updated medical assessment and reappraisal. Licensee will email proof of correction to Socorro.Leandro@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) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024

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: A HELPING HAND SOUTH BAY	FACILITY NUMBER: 197607231
	VISIT DATE: 08/29/2024

NARRATIVE

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The facility is a one-story house located in a residential street. The home consists of 5 resident bedrooms, 1 staff room, 2 bathrooms, 1 toilet room, 1 living room, 1 kitchen/dining/family room area, and a backyard patio area with shaded seating. There is a detached garage. The detached garage has 1 laundry room, 1 bathroom, 1 kitchen/bedroom/living room area, and 1 garage room used for storage.

Outside grounds were toured and no bodies of water were observed. The patio furniture is under a shaded area and accessible to residents. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

LPA toured the kitchen area and observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxics were kept in locked storage cabinet.

LPA observed that medications were safe, locked, and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. LPA did not observe documentation of when residents take their PRN medications. Documents are posted as mandated. Last drill was conducted on 06/20/2024. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational. There is a fire extinguisher in the kitchen area and it was purchased on 09/24/2024.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024

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: A HELPING HAND SOUTH BAY	FACILITY NUMBER: 197607231
	VISIT DATE: 08/29/2024

NARRATIVE

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5 out of 5 resident’s bedrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries accessible to residents. LPA tested hot water temperature and it measured between 105 and 120 degrees Fahrenheit. This facility provides residents with hygiene products such as feminine napkins, nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb.

5 staff records were reviewed. 5 resident records were reviewed and, 4 out of 5 resident records had required documentation. 1 resident record did not have their yearly Medical Assessment and Reappraisal/Appraisal & Needs Services Plan.

Deficiencies are being cited based on LPA observation and record review in accordance with the California Code of Regulations, Title 22. Deficiencies regarding documentation of PRN medications and yearly Medical Assessments and Reappraisals for residents with dementia.

An exit interview was conducted, and a copy of this report was left with the Administrator along with their appeal rights.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024

LIC809 (FAS) - (06/04)

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