198201977-9-1-2023-11-AS-WGIS-CV9SU8-20230901141042

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198201977
Report Date: 09/01/2023
Date Signed: 09/01/2023 02:10:50 PM

Document Has Been Signed on 09/01/2023 02:10 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	SANCTUARY, THE		FACILITY NUMBER:	198201977
ADMINISTRATOR:	CATHERINE RAYMUNDO		FACILITY TYPE:	740
ADDRESS:	21410 MADRONA AVENUE		TELEPHONE:	(424) 558-3134
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90503
CAPACITY:	6	CENSUS: 4	DATE:	09/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:20 AM
MET WITH:	Catherine Raymundo		TIME COMPLETED:	02:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 09/01/23, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced annual visit to the facility listed above. LPA met with Staff Erlinda Apalit, and explained the purpose of today's visit. We were later joined by Administrator, Catherine Raymundo. The facility currently has 4 resident's residing in the home. During time of visit, there were 3 residents present. Structure The facility is a single-story home in a residential neighborhood. The facility consists of 3-resident rooms, 1-resident bathroom, living room, family room, dining room, kitchen, 1-staff room, 1-staff bathroom, staff office, and attached garage. Physical Plant LPA and Staff toured the facility. The back yard has a table with an umbrella and chairs for residents use. All walkways were clean, clear and free of debris, hazards, and obstructions. The backyard is maintained by a private gardener. The gates on the side of the house open easily to exit. LPA did not observe any bodies of water on the premises. Bedrooms LPA inspected all resident bedrooms. All rooms for resident use had the required furniture including a bed, dresser, nightstand, and storage space for client’s personal belongings. All beds were observed to have the required linens including mattress cover, fitted sheets, blankets, comforter, and pillows. LPA observed adequate lighting in all bedrooms. LPA observed an adequate supply of bed linens in good repair. All bedrooms were observed to be clean and in good repair. Bathrooms The bathroom was observed to be within Title 22 regulations. It was observed clean, sanitary, and operational. The shower were free of mold and mildew. The shower had a nonskid mat, shower chair and secured safety handrails. The water temperature measured 119.8-degrees Fahrenheit. LPA observed an adequate supply of towels and hygiene products. Kitchen LPA observed the kitchen to be clean and sanitary. All appliances including stove, oven, refrigerator, microwave, and dishwasher were in good working repair. LPA observed an adequate supply of cutleries, pots, and pans. LPA observed a 3- day supply of perishable foods and a 7- day supply of nonperishable foods. CONTINUED ON LIC9099-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

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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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: SANCTUARY, THE	FACILITY NUMBER: 198201977
	VISIT DATE: 09/01/2023

NARRATIVE

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All sharps are secured in a locked drawer in the kitchen and are inaccessible to residents. Cleaning supplies are secured in a locked closet in the hallway and are inaccessible to residents. The water temperature measured 118.4-degrees Fahrenheit.
Common Rooms The den has two couches, that accommodate all residents. LPA observed a fireplace that was screened and inaccessible to residents. In the family room, LPA observed, 4 recliners for resident use. LPA observed books and magazines in the entertainment center. The dining room has a long oval table to accommodate all residents. LPA observed all walkways and hallways in the facility to be clean and free of obstructions or hazards. All common rooms have adequate lighting.
Safety LPA observed smoke detectors in all rooms that are fully operational. LPA observed a carbon monoxide detector in the living room. LPA observed a fully charged fire extinguisher mounted on a wall in the kitchen, that was last serviced on 08/11/23. The last emergency drill was conducted on 02/03/23. All emergency personnel numbers were posted. The facility has a working landline telephone. On a wall in the family room, LPA observed all required posting including the Emergency and Disaster Plan, License, Licensing reports, Personal Rights, Nondiscrimination Notice, Complaint Information, Long-Term Ombudsman, Activity schedule, and Theft and Loss Policy.
Medications LPA reviewed the medications and medication administration record (MAR) for two residents. LPA observed the medications in their original packaging. The medication is consistent with the MARs. Medications are secured in locked cabinet in the kitchen and are inaccessible to residents.
File Review & Interviews LPA reviewed two resident files and found it contained the required documents. LPA interviewed 3 residents, and they were all happy with the care and services they receive at the facility. LPA reviewed the Administrator, and 2 staff files and found they contained the required certification, training, and documents. LPA interviewed staff that was at the facility, and they were able to answer questions regarding personal rights, care, policy, and procedure.

Infection control Before entry, LPA called to do a risk assessment and the facility is free of Covid. Upon entry LPA was screened for Covid-19 and temperature was taken. LPA observed a sanitizing station and sign in log at the entrance of the facility. LPA observed a 60-day supply of PPEs, stored in a cabinet in the garage and additional supply secured in a locked closet in the hallway. LPA observed infection control signs posted throughout the facility

Deficiencies are being cited based on LPA observations, interviews conducted and record reviews in accordance with the California Code of Regulations, Title 22, please see LIC809-D.

An exit interview was conducted with Administrator Catherine Raymundo and a copy of this report and the Appeals Rights was provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/01/2023 02:10 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SANCTUARY, THE	FACILITY NUMBER: 198201977
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

1569.695 Emergency Plans (c) A facility shall conduct a drill at least quarterly for each shift. They type of emergency covered in a drill shall vary from quarter to quarter, taking into account differenct emergency scenarios. An actual evacuation of resident is not required during the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews and record review, the licensee failed to ensure that facility conducts emergency drills at least quarterly for each shift, which poses a potential health and safety risk to clients in care.
	POC Due Date: 09/15/2023
	Plan of Correction
1 2 3 4	The licensee stated that an emergecy drill will be conducted. Proof of corrections will be submitted to CCLD by POD due date.

Type B

Section Cited

CCR

87303(a)

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provisions of maintenance services and procedures for the safetyand well-being of residents, employees and visitors, This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above due to the back screen doot to the backyard is off the track and is difficult to open, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/15/2023
	Plan of Correction
1 2 3 4	The Lisencess shall ensure the above deficieny will be cleared by the POC due date. Proof of corrections shall be submitted to CCLD via email to wendy.gibbs@dss.ca.gov by the POC due date.

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	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

LIC809 (FAS) - (06/04)

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