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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608376
Report Date: 03/10/2022
Date Signed: 03/16/2022 02:05:40 PM

Document Has Been Signed on 03/16/2022 02:05 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:REDONDO BEACH ELDERLY HOMEFACILITY NUMBER:
197608376
ADMINISTRATOR:RHODA MABUTASFACILITY TYPE:
740
ADDRESS:18312 MANSEL AVENUETELEPHONE:
(310) 371-7193
CITY:REDONDO BEACHSTATE: CAZIP CODE:
90278
CAPACITY: 12CENSUS: 12DATE:
03/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jake Amoyot, House ManagerTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA's) Ana Soto and Jeremiah Randle conducted an unannounced Annual required visit and an infection control inspection to the above facility. LPA was met by Jake Amoyot, and later met with JM, area manager and the purpose of today’s visit was explained.

There are currently (12) residents in the facility. (5) residents are ambulatory and (7) are non-ambulatory. The facility is a single-story structure located in a residential neighborhood. It has a ramps that go along the north and south side of the facility. It consists (9) bedrooms, (3) full bathrooms and (2) half baths shaded front and side yard, laundry room in the attached 2 car garage.

LPA and Jake toured the entire facility inside and out. Documents are posted as mandated. Bedrooms 1-8 are occupied by residents and contain the mandated furniture. Bedroom 9 is a staff bedroom. The (5) bathrooms are clean and operational. First aid kit completes with manual; smoke detectors and carbon monoxide detector were inter-connected and in compliance and operational. No firearms are stored at facility and a fountain is in the front but has no water. Medications are stored, locked and inaccessible to residents. 2 staff files and 2 resident files with medications are current. Ample supply of perishable and nonperishable food, hot water temperature is 108.5 degrees Fahrenheit, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents, 3 fire extinguishers are fully charged. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in good repair. During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry, visitors are logged, and temperature checked, sanitizer/soap in the bathrooms and additional sanitation supplies are locked in the garage. LPA observed staff and clients wearing masks, residents’ private rooms will be converted to isolation rooms (if needed) and shared rooms will be relocated to a private room and private resident will be in a shared room (if needed.) The required postings throughout the facility. The facility has an approved and posted Mitigation plan. The resident’s temperatures are checked and logged 2x a day. PPE's are enough for 30 days.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview conducted with JM, area manager and copy of report provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2022
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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