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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803954
Report Date: 08/07/2022
Date Signed: 08/17/2022 04:54:39 AM

Document Has Been Signed on 08/17/2022 04:54 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:AMYTONY HOME IVFACILITY NUMBER:
197803954
ADMINISTRATOR:MELANIE ESTEPAFACILITY TYPE:
735
ADDRESS:1924 SHIPWAY AVENUETELEPHONE:
(562) 795-9162
CITY:LONG BEACHSTATE: CAZIP CODE:
90815
CAPACITY: 4CENSUS: 4DATE:
08/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:Celina Cataluna & Maria SunioTIME COMPLETED:
02:31 PM
NARRATIVE
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On 08/07/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA met with administrators Maria Sunio and Celine Cataluna and explained the purpose of today’s visit. The facility is licensed to operate for (4) non-ambulatory disability disable adults ages 18 – 59 years of age. The clients are Harbor Regional Center consumers.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) client’s rooms, two (2) common bathrooms, living area, dining area, kitchen, and outside covered patio area.

LPA toured the physical plant. There were no obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in adequate condition. There were ample storage for client’s personal belongings. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be operational. The water temperature measured 109.6 F. A comfortable temperature of 74 degrees was maintained in the facility.

LPA observed the facility to be furnished at the time of visit. Storage areas for personal hygiene were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. The facility has (1) fire extinguisher that is charged, smoke detectors operable. A working landline telephone remains available. A review of Medication Administration Record (MAR) and Fire Drill were found to be maintained in order. The last fire drill was conducted on 08/02/22 at 2pm.

Evaluation Report continues on LIC 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2022
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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Document Has Been Signed on 08/17/2022 04:54 AM - It Cannot Be Edited


Created By: Ernand Dabuet On 08/07/2022 at 01:19 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: AMYTONY HOME IV
FACILITY NUMBER: 197803954

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that 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 and identifed cleaning solutions and toxic chemicals in laundry sink and underneath bathroom sink. This violaiton which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2022
Plan of Correction
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The licensee will adher
e to Title 22 Section 80087. The licensee will perform knowledge of and conform to applicable laws, rules, and regulations. Plan of correction will be submitted by POC due date: 08/08/22 with proof of hazardous items are stored in locked cabinets.
*This citation was cleared on visit.*
Type A
Section Cited
CCR
80087(g)(1)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

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 identified (2) sharp scissors in unlocked kitchen drawer. This violation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2022
Plan of Correction
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The licensee will adhere to Title 22 Section 80087. The licensee will perform knowledge of and conform to applicable laws, rules, and regulations. Plan of correction will be submitted by POC due date: 08/08/22 with proof of sharp objects that may cause harm to client's in care are stored in locked cabinets.
*This citation was cleared during visit.*
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/17/2022 04:54 AM - It Cannot Be Edited


Created By: Ernand Dabuet On 08/07/2022 at 01:20 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: AMYTONY HOME IV
FACILITY NUMBER: 197803954

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 kitchen cabinets, stove overhead hood vent, and disshwasher uncleaned and unsanitary. The violation which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/22/2022
Plan of Correction
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The licensee will adhere to Title 22 Section 80087. The licensee will perform knowledge of and conform to applicable laws, rules, and regulations. Plan of correction will be submitted by POC due date: 08/22/22 proof of deep cleaning throughout the kitchen area.
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

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 with showers both unsanitary conditions. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/22/2022
Plan of Correction
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The licensee will adhere to Title 22 Section 80088. The licensee will perform knowledge of and conform to applicable laws, rules, and regulations. Plan of correction will be submitted by POC due date: 08/22/22 proof of deep cleaning throughout the bathroom showers.
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2022


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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: AMYTONY HOME IV
FACILITY NUMBER: 197803954
VISIT DATE: 08/07/2022
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INFECTION CONTROL:
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 staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff tests and residents' vaccination along with daily temperature checks were conducted. The facility has an approved Mitigation Plan Report on file with CCLD.

DEFICIENCIES:
At 10:20 am, LPA identified bleach cleaning solution inside the laundry sink. At 10:25 am, LPA observed cleaning solutions under the bathroom sink in bathroom #2. At 10:24 am, LPA observed showers in bathrooms #1 and #2 uncleaned and unsanitary condition. At 10:30 am, LPA identified kitchen cabinets, stove and over range hooded vent filled with grime and grease. At 10:32 am, LPA identified a working dishwasher uncleaned and unsanitary with fungus.

Deficiencies are issued and an exit interview is conducted with Maria Sunio. A copy of this report is provided along with the appeal rights.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2022
LIC809 (FAS) - (06/04)
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