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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803954
Report Date: 10/23/2023
Date Signed: 10/23/2023 11:53:33 AM

Document Has Been Signed on 10/23/2023 11:53 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 ASC, 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: 2DATE:
10/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
07:56 AM
MET WITH:MARIA SUNIOTIME COMPLETED:
12:15 PM
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10/23/2023, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with administrators Maria Sunio and Staff 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. Currently there are three (3) Residents in place; (2) residents are present at the time of the visit, and one (1) is in the hospital.

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 hot water temperature measured 131.6 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 land line 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 05/03/23.

Evaluation Report continues on LIC 809-C

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: AMYTONY HOME IV
FACILITY NUMBER: 197803954
VISIT DATE: 10/23/2023
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During the visit, LPA observed the facility's infection control practices. LPA observed sanitizing stations in common areas. 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. The facility has an approved Mitigation Plan Report on file with CCLD. The License fees are current.

Deficiency was issued and an exit interview is conducted with Maria Sunio. A copy of this report is provided along with the appeal rights.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023
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Document Has Been Signed on 10/23/2023 11:53 AM - It Cannot Be Edited


Created By: Antonine Richard On 10/23/2023 at 11:26 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: AMYTONY HOME IV
FACILITY NUMBER: 197803954

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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. The hot water temperature controls shall be maintained and delivered hot water between 105 and 120 degrees and not more than 120 degress, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2023
Plan of Correction
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The administrator will adhere to Title 22 Section 80088(e)(1). The administrator will ensure the hot water temperature controls are maintained to regulate temperature at 105 to 120 degrees. Plan of correction will be submitted by POC due date: 10/24/23 to LPA 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: 10/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2023


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