198203584-12-11-2023-11-AS-RCLD-CYEV69-20231211150911

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198203584
Report Date: 12/11/2023
Date Signed: 12/11/2023 03:09:35 PM

Document Has Been Signed on 12/11/2023 03:09 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	AUNT MONA'S CARE HOME, INC.		FACILITY NUMBER:	198203584
ADMINISTRATOR:	MONA MCCALLISTER		FACILITY TYPE:	740
ADDRESS:	2522 SUNNYSIDE RIDGE RD.		TELEPHONE:	(310) 833-3131
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90275
CAPACITY:	6	CENSUS: 4	DATE:	12/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Gregg MacEllvem		TIME COMPLETED:	03:30 PM

NARRATIVE

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On 12/11/2023 at 9:20 AM, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced Required – Annual Inspection and met with House Manager Sheryll Tilan. Gregg MacEllvem joined us 30 minutes later. Four (4) residents and three (3) staff were present during this inspection.

Facility is licensed to serve licensed for 6 non-ambulatory clients ages 60 and above; approved for 6 hospice and approved for 6 bedridden residents.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: It (6) bedrooms, (3) full bathrooms, Surveillance cameras system, ramp along side back of facility, laundry room/office, living room, fire place, dining room, shaded back yard with ramp on back porch, front yard and porch, and attached 2 car garage.

Staff accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards.

Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises.

Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, hot water temperature properly measured between 119F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked.

Common areas were clean and clear of hazards, doorways were free of obstructions.

Continue to LIC 809-C

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

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 12/11/2023 03:09 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: AUNT MONA'S CARE HOME, INC.	FACILITY NUMBER: 198203584
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Deficiency Dismissed

Type A

Section Cited

CCR

87355(e)(3)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above for staff # 1 which poses an immediate safety risk to persons in care. LPA Cloyd did not find staff #1 associated to facility 198203584 and staff #1 was working on-site during the time of inspection.
	POC Due Date: 12/12/2023
	Plan of Correction
1 2 3 4	Gregg MacEllvem will complete a criminal background clearance transfer request for staff #1 and email it to regina.cloyd@dss.ca.gov by 12/12/2023. Gregg will ensure that the administrator will make sure all individuals working, residing or volunteering in the facility is associated with facility 198203584.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: AUNT MONA'S CARE HOME, INC.	FACILITY NUMBER: 198203584
	VISIT DATE: 12/11/2023

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LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxics were kept in locked storage cabinet. First Aid kit was available. One fire extinguisher, last serviced August 17, 2023 was observed in the dining room. LPA tested all carbon monoxide detectors and smoke detector which are interconnected. Both devices were functional.

Four staff records were reviewed and two staff members were interviewed.

Four resident records were reviewed and, four out of four client records had, Medical Assessments. Two residents’ medication was reviewed.

Deficiencies are being cited based on LPA observation, interviews conducted and record review in accordance with the California Code of Regulations, Title 22, see LIC809D. A violation regarding transfer of a criminal record clearance for staff #1 warrants an immediate civil penalty of $500.00 and is hereby assessed, see LIC421BG. LPA Cloyd did not find staff #1 in Guardian and the staff was on-site working during the inspection.

An exit interview was conducted, plans of corrections were developed and reviewed. A copy of this report and appeal rights were discussed and left with Gregg MacEllvem.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

LIC809 (FAS) - (06/04)

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