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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608102
Report Date: 02/17/2023
Date Signed: 02/17/2023 12:46:05 PM

Document Has Been Signed on 02/17/2023 12:46 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: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:
02/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:41 AM
MET WITH:Jocelyn Letigio and Christian EspinoTIME COMPLETED:
01:00 PM
NARRATIVE
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On 2/17/23, Licensing Program Manager (LPM) Ulysses Coronel and Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced Annual required visit with a primary focus on infection control measures. The team was met by Jocelyn Letigio,staff. The purpose of today's was explained. The facility is licensed to serve 6 Elderly residents Age 60 and Above. Fire Cleared for (4) Bedridden and two(2) Non-Ambulatory. Approved to accept or retain four (4) residents on Hospice.

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 staff Jocelyn Letigio 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 hot water temperature was 141.3F.

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, two (2) carbon monoxide units are operable. LPA observed a Scissor in outside cabinet was accessible.

During the visit, (LPA) observed the facility infection control practices. observed screening protocols for visitors, staff and residents, sanitizing stations (located in area in the living room. LPA observed staff were wearing face coverings, and isolation required postings throughout the facility. LPA observed the facility has 30 days supply of Personal Protective Equipment (PPE).
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
Document Has Been Signed on 02/17/2023 12:46 PM - It Cannot Be Edited


Created By: Antonine Richard On 02/17/2023 at 10:53 AM
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
MONTEREY PARK, CA 91754

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(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 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) the licensee did not comply with the section cited above in the hot water temperature tested at 141.3F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/18/2023
Plan of Correction
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The staff adjusted the water temperature between 105 and 120F. The Administrator will create a plan to ensure future compliance. The Administrator will submit proof of correction via email to antonine.richard@dss.ca.gov.
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:Ulysses Coronel
LICENSING EVALUATOR NAME:Antonine Richard
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2023


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 02/17/2023 12:46 PM - It Cannot Be Edited


Created By: Antonine Richard On 02/17/2023 at 10:53 AM
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
MONTEREY PARK, CA 91754

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation), the licensee did not comply with the section cited above,LPA observed a scissor in outside cabinet was accessible] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2023
Plan of Correction
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Stall removed the scissor during today's visit. Administrator will create a plan correction to ensure compliance The Administrator will submit proof of correction via email to antonine.richard@dss.ca.gov.
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:Ulysses Coronel
LICENSING EVALUATOR NAME:Antonine Richard
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2023


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: KIND HEART HOME CARE III
FACILITY NUMBER: 197608102
VISIT DATE: 02/17/2023
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LPA advised the Administrator to continuously monitor the CenterCDC) website and Community Care Licensing Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

During today's visit there were deficiencies observed. The hot water temperature was 141.3F. LPA observed a Scissor in outside cabinet was accessible. Title 22 regulations please see LIC809D.

Exit interview held, and plans correction developed. a copy of the report and appeals rights was provided to Christian Espino.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023
LIC809 (FAS) - (06/04)
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