198203919-11-3-2022-11-AS-ASOO-CKNT5Q-20221029142556

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198203919
Report Date: 10/29/2022
Date Signed: 11/03/2022 04:36:43 PM

Document Has Been Signed on 11/03/2022 04:36 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:	TLC GUEST HOME II		FACILITY NUMBER:	198203919
ADMINISTRATOR:	MUQEET "MD" DAABHOY		FACILITY TYPE:	740
ADDRESS:	28024 CALZADA DR.		TELEPHONE:	(310) 548-0898
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90275
CAPACITY:	6	CENSUS: 5	DATE:	10/29/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Edilberto Bernardino, Administrator		TIME COMPLETED:	01:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Ana Soto conducted an unannounced Annual required and infection control visit to the above facility. LPA was met by Edilberto Bernardino, Administrator and the purpose of today’s visit was explained.

There are currently (5) residents in the facility. (1) residents are ambulatory, (3) are non-ambulatory, (1) bedridden. The facility is a single-story structure located in a residential neighborhood. It consists (5) bedrooms, (2) full bathrooms, no shade in back yard, front yard, laundry room in a attached 2 car garage.

LPA and Miriam toured the entire facility inside and out. Documents are posted as mandated. Bedrooms 1-4 are occupied by residents and contain the mandated furniture. Bedroom 5 is a staff bedroom. The (2) bathrooms have grab bars and non-skid mats and are clean and operational. First aid kit is fully stocked with manual; no smoke detector the living room, dining room, and kitchen(open concept home.) The stove oven is not working. Smoke detectors in rooms and carbon monoxide detector 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. (1) Resident file along with medications are current. (1) Staff file was current(CPR card exp 06/2021.) Ample supply of perishable and nonperishable food, hot water temperature is (107.4) degrees Fahrenheit, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents, (1) fire extinguisher is fully charged. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in good repair.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2022

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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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: TLC GUEST HOME II	FACILITY NUMBER: 198203919
	VISIT DATE: 10/29/2022

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. During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry & visitors and temperatures are logged and checked, sanitizer/soap, paper towels, in all the bathrooms and additional sanitation supplies are stored in the garage. LPA observed staff wearing masks, resident private rooms will be converted to isolation rooms (if needed) trash cans with lids, No cart for PPE’s, mitigation plan posted and/or in folder, Fit testing completed for staff, and required postings throughout the facility. Visitor designated area, facility has internet & Lap top for residents to use, resident’s temperatures are checked and logged (three times a day). Emergency contacts updated and posted; PPE's are enough for 30 days. All residents and staff are vaccinated and boosted

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued a citation.

Technical Advisory (TA) issued.

1. No cart for PPE's

An exit interview conducted with Edilberto Bernardino, Administrator and a hard copy of report provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/03/2022 04:36 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: TLC GUEST HOME II	FACILITY NUMBER: 198203919
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited


	Deficient Practice Statement
1 2 3 4	87468.1(a)(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This was not met as evidence by: Based on no umbrella for shade in the back yard and stove oven not working. Which poses a potential health snd safety risk for all persons in care.
	POC Due Date: 11/05/2022
	Plan of Correction
1 2 3 4	Administrator to purchase an umbrella for the back yard for shade and provide a receipt and photo of umbrella purchase. Send it to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4	Health and Safety 1569.699 When approved by the person responsible for enforcement as described in Section 13146, exit doors in facilities classified as Group R, Division 2 facilities under the California Building Standards Code, licensed as residential care facilitie.....:This was not met as evidenceby: Based on no smoke detedtor to cover kitchen, dining room or living room(open concept design)Which poses a potentila health and risk for all persons in care.
	POC Due Date: 11/04/2022
	Plan of Correction
1 2 3 4	Administrator to purchase a battery operated smoke detector and take picture of receipt and smoke detector and send to LPA by 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: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2022

LIC809 (FAS) - (06/04)

Page: 4 of 4

Document Has Been Signed on 11/03/2022 04:36 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: TLC GUEST HOME II	FACILITY NUMBER: 198203919
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited


	Deficient Practice Statement
1 2 3 4	87411(c)(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This was not met as evidenced by: Based on 1 staff had an expired CPR certificate. Which poses a potential health and safety risk for all persons in care.
	POC Due Date: 11/04/2022
	Plan of Correction
1 2 3 4	Administrator to take training and get new CPR certificate and provide picture to LPA by POC due date.

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: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4