197607349-7-25-2022-11-AS-LMOA-CGNTPQ-20220725145442

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607349
Report Date: 07/22/2022
Date Signed: 07/25/2022 02:54:53 PM

Document Has Been Signed on 07/25/2022 02:54 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	J & A COMPASSIONATE CARE II		FACILITY NUMBER:	197607349
ADMINISTRATOR:	ALICE GALANG		FACILITY TYPE:	740
ADDRESS:	2160 W. 236TH STREET		TELEPHONE:	(310) 326-2868
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90501
CAPACITY:	6	CENSUS: 5	DATE:	07/22/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	ANGELITO COSTA/ALICE GALANG		TIME COMPLETED:	03:30 PM

NARRATIVE

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On 7/22/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. Upon arrival, LPA called the facility to conduct a risk assessment. LPA spoke with Licensee Alice Galang, who confirmed the facility is Covid-19 free. LPA met with House Manager Angelito Costa shortly after and explained the purpose of today's visit.

Upon arrival at the facility, LPA met with Facility House Manager, Angelito Costa, who granted access and allowed LPA to enter the facility to conduct an annual inspection. Administrator Alice Galang joined the visit shortly after. The facility is licensed for elderly residents ages 60 and older, cleared for six (6) bedridden residents. Hospice waiver granted for one (1) terminally ill resident. There is one bedridden resident on today’s visit. The administrator’s certificate expires on 8/29/22.

During the visit, LPA toured the facility with HM Angelito Costa. This facility consists of four (4) resident bedrooms, one (1) staff bedroom, three (3) bathrooms, kitchen, living room/TV room, dining room, shaded patio and a garage. Operable smoke detectors in bedrooms and hallways were observed. One carbon monoxide detector located near the main entrance door is operable. One fire extinguisher last serviced on 9/30/2021 located near the main entrance door. The last facility fire drill was on 6/6/2022. LPA observed the facility is clean, sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, and toxins were stored and not accessible to resident. The kitchen was inspected and there is sufficient perishable and non-perishable food available.

Report Continued in LIC 809-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: J & A COMPASSIONATE CARE II	FACILITY NUMBER: 197607349
	VISIT DATE: 07/22/2022

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There are no pools or bodies of water on the premises. There are no firearms on the premises and other dangerous weapons. Potentially dangerous items are kept inaccessible to residents with dementia. Centrally stored medications are locked in a cabinet located in the kitchen. The first aid kit has all the required supplies. Toxic chemicals are locked in a cabinet in the kitchen. The facility has a written emergency disaster plan posted on the bulletin in the dining room. The facility is maintained at a comfortable temperature. There are working lights or lamps in each room at the time of visit. There are grab bars for each toilet and shower used by residents. Showers have non-skid mats.

During the visit, LPA observed the following to be in compliance: the facility's infection control practices; sanitizing stations in common areas and restrooms; every staff was wearing a face covering; the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has a Mitigation Plan Report approved by CCLD.

According to California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed deficiencies and cited in LIC 9099D. A technical assistance was issued to licensee.

An exit interview was conducted and a copy of the Facility Evaluation Report and Appeal Rights were provided to Licensee Alice Galang.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/25/2022 02:54 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: J & A COMPASSIONATE CARE II	FACILITY NUMBER: 197607349
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(j)

Care of Persons with Dementia

(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above. LPA Montoya observed the sliding between the living room and the shaded patio has no auditory device to monitor exits for residents with dementia. The facility presently has three (3) residents with dementia of which two are ambulatory. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/29/2022
	Plan of Correction
1 2 3 4	Licensee installed an auditory device on the sliding door. This deficiency was corrected during the visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 07/25/2022 02:54 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: J & A COMPASSIONATE CARE II	FACILITY NUMBER: 197607349
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more 120 degrees F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above. LPA observed the water temperature was measured at 103.6 degrees F in bedroom #1, 102.9 degrees F in the full common bathroom and 101.8 degrees F in the common half bathroom. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/23/2022
	Plan of Correction
1 2 3 4	Licensee agreed to adjust the water temperature in all three bathroom and maintain the temperature between 105 - 120 degrees F. Proof of correction shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022

LIC809 (FAS) - (06/04)

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