197607907-11-15-2022-11-AS-DSEA-CL2RTU-20221110121856

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607907
Report Date: 11/10/2022
Date Signed: 11/15/2022 11:37:53 AM

Document Has Been Signed on 11/15/2022 11:37 AM - 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:	TWIN HOMECARE - B		FACILITY NUMBER:	197607907
ADMINISTRATOR:	ADELITA STUCHLAK		FACILITY TYPE:	740
ADDRESS:	2106 W. 242ND STREET		TELEPHONE:	(424) 263-4849
CITY:	LOMITA	STATE: CA	ZIP CODE:	90717
CAPACITY:	6	CENSUS: 6	DATE:	11/10/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:59 AM
MET WITH:	House Manager - Josefina Nicolas		TIME COMPLETED:	12:18 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 11/10/2022, Licensing Program Analyst (LPA) Don Senaha conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with House Manager Josefina Nicolas and called Administrator Roneilio Garcia on the phone and explained the purpose of today’s visit. The facility is licensed to operate for six (6) elderly residents ages 60 and above. The facility is approved for six (6) non-ambulatory residents of which six (6) may be bedridden and may retain four (4) hospice. The facility is a single-story structure located in a residential neighborhood. The facility consists of the following: six (6) resident's rooms, a staff room, four (4) bathrooms, a living room area, dining area and kitchen. There is a garage used for storage only. The washer and dryer are located in a closet space next to the garage. There is a patio area with an umbrella for shade and ample seating for the residents. LPA and house manager toured the physical plant. There are 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 met Title 22 requirements in the kitchen and bathrooms. A comfortable temperature was maintained in the facility. Evaluation Report Continues on LIC 809-C

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Don Senaha	TELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022

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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: TWIN HOMECARE - B	FACILITY NUMBER: 197607907
	VISIT DATE: 11/10/2022

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 and toxins were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly. There was one (1) fire extinguisher fully charged located in the kitchen area. First aid kit was available. Smoke detectors and carbon monoxide were operable. A review of 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 six (6) clients and two (2) staff present during the tour. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE) with most of the PPE located in the garage. All mandated inspection control posters were posted.

Advisory Notes – One (1) Technical Assistance were issued, please see LIC9102-AN.

There were two deficiencies cited during this inspection visit. See 9099D page.

An exit interview was conducted and a copy of this report was provided to House Manager Josefina Nicolas.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Don Senaha	TELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/15/2022 11:37 AM - 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: TWIN HOMECARE - B	FACILITY NUMBER: 197607907
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. There were unlocked sharps and knives in two drawers which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/11/2022
	Plan of Correction
1 2 3 4	Licensee immediately removed the sharps and locked them. Licensee to do in-service training and sent LPA copy via email.

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: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Don Senaha	TELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 11/15/2022 11:37 AM - 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: TWIN HOMECARE - B	FACILITY NUMBER: 197607907
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. 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. The stove is not in good repair and two of the four burners do not work and have to be lit by flame which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/12/2022
	Plan of Correction
1 2 3 4	Licensee to fix/replace the stove two of four burners and send LPA copy of receipt of purchase and video of all burners working by POC due date of 12/12/22.

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: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Don Senaha	TELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022

LIC809 (FAS) - (06/04)

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