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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198201977
Report Date: 08/03/2022
Date Signed: 08/04/2022 09:32:04 PM


Document Has Been Signed on 08/04/2022 09:32 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:SANCTUARY, THEFACILITY NUMBER:
198201977
ADMINISTRATOR:CATHERINE RAYMUNDOFACILITY TYPE:
740
ADDRESS:21410 MADRONA AVENUETELEPHONE:
(424) 558-3134
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY:6CENSUS: 5DATE:
08/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Catherine RaymundoTIME COMPLETED:
04:00 PM
NARRATIVE
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On 8/3/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. Upon arrival at the facility, LPA Montoya called the facility, spoke with Administrator Catherine Raymundo and conducted a risk assessment. Based on the assessment, the facility is clear of Covid-19 infection. LPA met with House Manager Linda Apalit and explained the purpose of the visit. Administrator Raymundo arrived later and joined the visit.

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

LPA Montoya toured and inside and outside grounds of the facility with the House Manager and the Administrator. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident 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 water temperature measured 99.4 degree Fahrenheit in residents' common bathroom and 99.3 degree Fahrenheit in resident bedroom #4. A comfortable temperature was maintained in the facility.

LPA observed the facility to be appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects 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 (2) fire extinguishers that were charged, smoke detectors, and carbon monoxide were operable. The facility conducted a Fire/Safety Drill on 8/3/2022. A working telephone remains available.

Evaluation Report Continues on LIC 809-C
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022
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 08/04/2022 09:32 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: SANCTUARY, THE
FACILITY NUMBER: 198201977

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2022

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 and interview, the licensee did not comply with the section cited above. LPA Montoya observed the water temperature in the residents' common bathroom is 99.4 degree Fahrenheit and 99.3 degree Fahrenheit in bedroom #4. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2022
Plan of Correction
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The administrator agreed to adjust the water temperature and maintain between 105-120 degree Fahrenheit. The administrator shall check and record the temperature every two hours. POC shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the due date, 8/4/2022.
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: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/04/2022 09:32 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: SANCTUARY, THE
FACILITY NUMBER: 198201977

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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. LPA Montoya observed the sliding door screen is torn on the lower right side. LPA observed the sidewalk on the side yard is dirty with dried bird droppings. LPA observed the outside patio furniture cover is dirty and has some dried bird droppings. LPA did not observe an umbrella for the patio furniture. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2022
Plan of Correction
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The administrator shall fix the sliding door screen and clean the side yard and the outdoor patio furniture. POC shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the due date, 8/15/2022.
Type B
Section Cited
CCR
87307(d)(7)
Personal Accommodations and Services
(7) Fireplaces and open-faced heaters shall be adequately screened.

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. LPA observed the fireplace is not adequately screened. It is covered with a cardboard. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2022
Plan of Correction
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The administrator shall install a screen and ensure the firepalce is adequately covered. POC shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the due date, 8/15/2022.

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 AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 08/04/2022 09:32 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: SANCTUARY, THE
FACILITY NUMBER: 198201977

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review and interview with the admnistrator, the licensee did not comply with the section cited above. LPA did not observe a Pre-placement Appraisal and Physician's Report for a resident (R#1) who was admitted on 7/5/2022. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2022
Plan of Correction
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The administrator shall ensure Resident #1 has a current physician's report and pre-appraisal on file. POC shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the due date, 8/15/2022.
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: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SANCTUARY, THE
FACILITY NUMBER: 198201977
VISIT DATE: 08/03/2022
NARRATIVE
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for residents, staff and visitors, and 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. The facility has an approved Mitigation Plan Report on file with CCLD.

Advisory Notes - Technical Assistance were issued, please see LIC9102-AN.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed deficiencies and issued citations.

An exit interview was conducted and a copy of this report and appeal rights were given to Administrator Catherine Raymundo
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5