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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608102
Report Date: 02/02/2022
Date Signed: 02/09/2022 04:53:03 PM

Document Has Been Signed on 02/09/2022 04:53 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
MONTERY PARK, CA 91754
FACILITY NAME:KIND HEART HOME CARE IIIFACILITY NUMBER:
197608102
ADMINISTRATOR:COTY LUBIANO-CABRALFACILITY TYPE:
740
ADDRESS:2033 W. 231ST STREETTELEPHONE:
(310) 782-5045
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 6CENSUS: 5DATE:
02/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:03 PM
MET WITH:COTY CABRALTIME COMPLETED:
03:40 PM
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On 2/2/2022, 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. LPA met with Administrator Coty Cabral who assisted LPA with the visit. LPA explained the purpose of today’s visit.

The facility is a two-story structure located in a residential neighborhood. It consists of the following: five (5) resident bedrooms and two (2) bathrooms, one (1) staff bedroom, a living area, dining area, kitchen, family room, and outside patio area on the first floor; two (2) bedrooms and one (1) bathroom on the second floor.

LPA and Administrator Coty Cabral toured the inside and outside of the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for client 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 measured 118.0 F. A comfortable temperature of 74 F was maintained in the facility.

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 clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available. Two fire extinguishers are charged and last serviced on 3/2/2021, two (2) carbon monoxide units are operable. A landline telephone (310) 530-4556 was available and operable.

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2022
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
MONTERY PARK, CA 91754
FACILITY NAME: KIND HEART HOME CARE III
FACILITY NUMBER: 197608102
VISIT DATE: 02/02/2022
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Medications are locked & centrally stored in a cabinet near the kitchen. The first aid kit has all required supplies.

During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed every staff was wearing a face covering. LPA observed 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.

LPA observed the following deficiency: Smoke detectors in a resident (R1) bedroom and staff room are not operable.

The above deficiency was cited (see LIC 809D) from the California Code of Regulations, Title 22. Exit interview conducted and appeal rights discussed. A copy of this report and appeal rights provided to the Administrator Coty Cabral.

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/09/2022 04:53 PM - It Cannot Be Edited


Created By: Lourdes Montoya On 02/02/2022 at 02:32 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
MONTERY PARK, CA 91754

FACILITY NAME: KIND HEART HOME CARE III
FACILITY NUMBER: 197608102

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
FIRE SAFETY - All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshall for the protection of life and property against fire and panic.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above: a smoke detector is inoperable in one (1) out of five (5) resident bedrooms and another smoke detector in a staff room is also inoperable. Based on LPA's review of physician's report, R1 is bedridden. This poses an immediate health, safety or personal rights risk to persons in care.

POC Due Date: 02/03/2022
Plan of Correction
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Administrator agreed to ensure smoke detectors in R1's bedroom and staff room are replaced with new batteries and operable. Administrator will submit to LPA Montoya a video of the smoke detectors and show that they are both operable by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Angela J Kendrick
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2022


LIC809 (FAS) - (06/04)
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