198203238-9-13-2023-11-AS-AINZ-CVMTA9-20230913143309

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198203238
Report Date: 09/13/2023
Date Signed: 09/13/2023 02:33:15 PM

Document Has Been Signed on 09/13/2023 02:33 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:	SOUTH BAY SENIOR LIVING		FACILITY NUMBER:	198203238
ADMINISTRATOR:	MAGGIE ORNELAS		FACILITY TYPE:	740
ADDRESS:	22711 S. VERMONT AVE.		TELEPHONE:	(310) 320-3318
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90502
CAPACITY:	70	CENSUS: 39	DATE:	09/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:01 AM
MET WITH:	Maggie Ornelas-Administrator		TIME COMPLETED:	02:30 PM

NARRATIVE

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On 9/13/2023, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required inspection using the CARES Inspection Tool. LPA met with Maggie Ornelas /Administrator. LPA explained the purpose of today’s visit. The facility is licensed to serve (70) elderly adults ages 60 and above, of which (70) may be non-ambulatory. Facility has an approved hospice waiver for (4).

The facility is a single-story structure located in a commercial neighborhood. It consists of the following: (35) resident bedrooms. Each room has a bathroom in the unit. The facility houses an activity room, dining area, kitchen, administrative offices, and outside patio area whit shade.

LPA Iniguez toured the physical plant with Administrator. There were no bodies of water or obstructions on the premises. A total of (5) rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected rooms: #159, #157, #155, #139 and #136; call buttons, and smoke and carbon monoxide are all operable conditions. The water temperature ranged from 109.5F° – 114.2F°. The rooms temperature ranged from 76F° – 78F°.

Evaluation Report continues on LIC 809-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023

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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Document Has Been Signed on 09/13/2023 02:33 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: SOUTH BAY SENIOR LIVING	FACILITY NUMBER: 198203238
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in not having a TB test on file for one of the staff(caregiver) which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/27/2023
	Plan of Correction
1 2 3 4	Licensee will ensure all staff has a curent TB on file. Licensee will send proof of correction to LPA vai email before 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: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023

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: SOUTH BAY SENIOR LIVING	FACILITY NUMBER: 198203238
	VISIT DATE: 09/13/2023

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LPA Iniguez observed the facility to be sanitary and appropriately furnished at the time of the 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. All fire extinguishers were charged and were operable. The last Fire/Disaster Drills were conducted on 08/29/20/23. Annual fire clearance performed on 1/20/20231. Working landline phones are available on-site. A review of (5) residents' service files (R1-R5) and (5) staff personnel files (S1-S5)-(see D page) and Medication Administration Records (MAR) were maintained in order.

LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted throughout the facility.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8.

An exit interview was conducted, and a copy of the Facility Evaluation Report and Appeal Rights was provided to the Administrator/ Maggie Ornelas.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023

LIC809 (FAS) - (06/04)

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