198203165-6-24-2023-11-AS-ARID-CT4VJT-20230624162917

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198203165
Report Date: 06/24/2023
Date Signed: 06/24/2023 04:29:24 PM

Document Has Been Signed on 06/24/2023 04:29 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:	MORNINGSIDE TERRACE		FACILITY NUMBER:	198203165
ADMINISTRATOR:	CESAR FELICIANO		FACILITY TYPE:	740
ADDRESS:	17219 ATKINSON AVENUE		TELEPHONE:	(310) 532-0257
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90504
CAPACITY:	6	CENSUS: 6	DATE:	06/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:38 PM
MET WITH:	BIEN CADUNGOG		TIME COMPLETED:	04:45 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 06/24/2023 Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced Annual required visit using the new Care Inspection Tool. LPA was met by Arturo cabico Care giver and later met with Bien Cadungog, Manager and the purpose of today’s visit was explained. There are currently (6) residents in the facility. (4) residents are ambulatory and (2) are non-ambulatory. The facility is a single story structure located in a residential neighborhood. It consists (7) bedrooms, (3) full bathrooms, shaded back yard, front yard, laundry room and a detached 2 car garage. LPA Richard and Cadungog, toured the entire facility inside and out. Documents are posted as mandated. Bedrooms 1-6 are occupied by residents and contain the mandated furniture. Bedroom (7) is a staff bedroom. The (3 ) bathrooms are clean and operational. First aid kit is fully stocked with manual, smoke detectors were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to residents. Reviewed residents and staff files. Ample supply of perishable and nonperishable food, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents, 2 fire extinguishers are fully charged. First Aid kit complete and with Manual. 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 staff bathroom and additional sanitation supplies are locked in the garage. According to the California Code of regulations (Title 22, Division 6, Chapter 8), LPA did observed deficiencies, The hot water temperature measured 124.2F and No carbon monoxide detectors at the facility.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Antonine Richard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2023

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: MORNINGSIDE TERRACE	FACILITY NUMBER: 198203165
	VISIT DATE: 06/24/2023

NARRATIVE

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. LPA observed staff and residents wearing masks, resident private rooms will be converted to isolation rooms (if needed) and required postings throughout the facility. The resident’s temperatures are checked and logged once a day. PPE's are enough for 30 days. According to the California Code of Regulations (Title 22, Division 6, Chapter 8),There were 2 deficiencies observed at the time of visit. therefore 2 citations were issued at this time.

An exit interview conducted and plan of corrections was developed. A copy of the report and appeal rights were provided to the manager Bien Cadungog,

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Antonine Richard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/24/2023 04:29 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: MORNINGSIDE TERRACE	FACILITY NUMBER: 198203165
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.311

Regulations

Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview)], the licensee did not comply with the section cited above in [(objects) [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/26/2023
	Plan of Correction
1 2 3 4	The facility Manager Bien Cadungog will create a plan to ensure compliance. Bien will submit proof of purshased of a new carbon monoxide detectors via email to LPA Antonine.Richard@dss.ca.gov

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
1 2 3 4	Based on [(observation) (interview) , the licensee did not comply with the section cited above in identifiers which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/25/2023
	Plan of Correction
1 2 3 4	The manager adjusted the hot water temperature between 118.6F and 117.5F. The manager will create a plan to ensure future compliance. The Manager will submit the plan of correction to LPA via email. Antonine.Richard@dss.ca.gov.

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	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Antonine Richard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2023

LIC809 (FAS) - (06/04)

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