197608102-1-29-2025-11-AS-RCLD-DDE26P-20250129160729

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608102
Report Date: 01/29/2025
Date Signed: 01/29/2025 04:07:41 PM

Document Has Been Signed on 01/29/2025 04:07 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:	KIND HEART HOME CARE III		FACILITY NUMBER:	197608102
ADMINISTRATOR/ DIRECTOR:	COTY LUBIANO-CABRAL		FACILITY TYPE:	740
ADDRESS:	2033 W. 231ST STREET		TELEPHONE:	(310) 782-5045
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90501
CAPACITY: 6		CENSUS: 4	DATE:	01/29/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:28 AM
MET WITH:	Christian Espino		TIME VISIT/ INSPECTION COMPLETED:	04:30 PM

NARRATIVE

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On 01/29/2025 around 9:30 AM, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced required – annual inspection and met with Staff Jocelyn. LPA spoke with the Administrator over the phone. The Administrator Assistant Christian Espino arrived later.

Facility is licensed to serve six (6) residents age 60 and above. It is cleared for four (4) bedridden and two (2) non-ambulatory rooms. Facility may accept or retain four (4) residents on hospice. The facility also has a sprinkler system. The landline number is 310-530-4556 and the annual fees are current.

The facility is a two-story structure located in a residential neighborhood. It consists of the following: six (6) resident bedrooms, one (1) staff bedroom, four (4) bathrooms, a living room, dining area, kitchen, family room, attached garage, and an outside patio area. The second floor has two (2) bedrooms and one (1) bathroom.

The Administrator Assistant accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. Common areas were clean and clear of hazards, doorways were free of obstructions.

Continue to LIC809-C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025

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 01/29/2025 04:07 PM - It Cannot Be Edited

Created By: Regina Cloyd On 01/29/2025 at 03:34 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
MONTEREY PARK, CA 91754

FACILITY NAME: KIND HEART HOME CARE III	FACILITY NUMBER: 197608102
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. 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 for two out of five staff membvers which poses/posed a potential health risk to persons in care. LPA did not observe health screenings, including TB results, for Staff #3 (S3) and #5 (S5).
	POC Due Date: 02/11/2025
	Plan of Correction
1 2 3 4	The Administrator will email health screening, including TB results, for Staff #3 and #5 to regina.cloyd@dss.ca.gov by the POC due date. The Licensee will ensure that all future staff will have completed their health screenings prior to working in the facility.

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:

Regina Cloyd

LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025

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: KIND HEART HOME CARE III	FACILITY NUMBER: 197608102
	VISIT DATE: 01/29/2025

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Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, and hot water temperature properly measured between 109 F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked.

LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxics were kept in locked storage cabinet. First Aid kit was available. Two fire extinguisher, last serviced February 14, 2024 was observed in the kitchen area and in the family room. Administrator tested the carbon monoxide detector and smoke detectors in the house. Both devices were functional.

Five staff records were reviewed and five out of five staff records had required criminal record clearances or criminal record exemptions.

Five resident records were reviewed and, five out of five resident records had medical assessments and pre-appraisal or reappraisals. Two residents’ medication was reviewed.

Deficiencies are being cited. During record review, LPA did not observe health screenings for Staff #3 (S3) and #5 (S5) (see LIC809-D).

An exit interview was conducted, technical assistance provided, Plan of Correction developed and a copy of this report with appeals documentation was discussed and left with Administrator Assistant Christian Espino.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025

LIC809 (FAS) - (06/04)

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