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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198203919
Report Date: 08/11/2023
Date Signed: 08/11/2023 07:28:05 PM


Document Has Been Signed on 08/11/2023 07:28 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:TLC GUEST HOME IIFACILITY NUMBER:
198203919
ADMINISTRATOR:MUQEET "MD" DAABHOYFACILITY TYPE:
740
ADDRESS:28024 CALZADA DR.TELEPHONE:
(310) 548-0898
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY:6CENSUS: 5DATE:
08/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:06 AM
MET WITH:RINO SANTOS TIME COMPLETED:
04:21 PM
NARRATIVE
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On 08/11/23, Licensing Program Analyst (LPAs) Ernand Dabuet and Socorro Leandro conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with lead caregiver Rino Santos. LPA explained the purpose of today’s visit. Muqeet Dadabhoy was unavailable to be present for the visit. The facility is licensed to operate for (6) non - ambulatory elderly adults ages 60 and above. Currently, the facility has (2) hospice resident in care. The facility is approved for (2) hospice resident.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: (4) residents' rooms, (2) bathrooms, (1) staff bedroom, a living area, a dining area, a kitchen, an outside seating area, and a garage.

LPAs toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 107.9 degrees F. A comfortable temperature of 75 degrees F. was maintained in the facility.

LPAs observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. A fire extinguisher was charged. A review of the Medication Administration Records (MAR) was observed to be maintained.

(Evaluation Report continues LIC 809-C)
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2023
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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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: TLC GUEST HOME II
FACILITY NUMBER: 198203919
VISIT DATE: 08/11/2023
NARRATIVE
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During the visit, LPAs observed the facility's infection control practices. LPAs observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPAs observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPAs observed First Aid Kit was maintained. A working landline phone was operational. The facility had operational smoke and carbon monoxide in bedrooms and common areas.

An audit of residents #1-#5 (R1-R5) service files and staff #1-#4 (S1-S4) personnel files. Interviews were conducted with (3) residents and (0) staff. The facility is not current on annual license fees and an invoice was left with Santos.

DEFICIENCIES:
  • Staff #1-#4 (S1-S4) all had expired CPR/First Aid.
  • No emergency drills (Fire/Earthquake) on record.
  • Administrators Certification for Teresita Castaneda and MuQueet DaDabhoy are expired.
  • Non-working rear stove burner and middle front burners.
  • Non-working oven door.
  • Stove hood require deep cleaning.
  • Electrical wire exposed in room #1 (missing electrical wall cover).
  • Pest in kitchen between refrigerator and cabinet.
  • Hazardous materials accessible to resident in care in patio area/exterior pathways.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies have been observed and citation issued (ref. LIC 9099-D).

In light of no administrators not available for this inspection visit, LPAs unable to obtain a copy of a Liability Insurance.

An exit interview conducted with Rino Santos, and a copy of report and appeal rights provided.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 08/11/2023 07:28 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: TLC GUEST HOME II
FACILITY NUMBER: 198203919

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (observation), the licensee did not comply with the section cited above. LPA identified hazardous items such as paint, decreaser, cleaning solutions accessible to residents with dementia. This violation poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/12/2023
Plan of Correction
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Licensee will adhere to Title 22 regulations 87309 and ensure to keep all hazardous material in locked storage. Proof of correction must be completed by POC 08/12/23.

Citation cleared during visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2023
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 08/11/2023 07:28 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: TLC GUEST HOME II
FACILITY NUMBER: 198203919

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Staff #1-#4 did not have current CPR/First Aid certificates. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2023
Plan of Correction
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Licensee will adhere to HSC 1569.618 regulations and ensure that all staff are current with CPR/First Aid training. Proof of correction must be sent by POC date: 08/25/23.
Type B
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above.LPA identified residue of roaches in ktichen. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2023
Plan of Correction
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Licensee will ensure to adhere to Title 22 87555 and ensure pest control service is completed in kitchen area. Proof of correction must be sent by POC due date: 08/25/23.
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 HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2023
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 08/11/2023 07:28 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: TLC GUEST HOME II
FACILITY NUMBER: 198203919

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (record review), the licensee did not comply with the section cited above. The faciilty has not conducted emergency fire/earthquake drills. No record logs were available. This violation] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2023
Plan of Correction
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Licensee will ensure to adhere to HSC 1569.695 and ensure to conduct emergency drills for fire and earthquake in a quarterly basis. Proof of correction must be sent by POC due date: 08/25/23.
Type B
Section Cited
CCR
87406(a)(g)
87406 Administrator Certification Requirements
(a) All individuals shall be residential care facility for the elderly certificate holders prior to being employed as an administrator. (g) Certificates issued under this section shall be renewed every two (2) years provided the certificate holder has complied with all renewal requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (record review), the licensee did not comply with the section cited above. Administrator Certification for Muqeet Dadabhoy and Teresita Castaneda had expired certificates. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2023
Plan of Correction
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Licensee will ensure to adhere to Title 22 87406 regulations and sent a renewal for CCLD Administrators Certification Program. Proof of correction must be sent by POC due date: 08/25/23.
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 HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 08/11/2023 07:28 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: TLC GUEST HOME II
FACILITY NUMBER: 198203919

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA identified exposed wiring in room #1 without electrical wall covering. Stove left rear burner and front middle burner not working as well as oven door. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/11/2023
Plan of Correction
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Licensee will ensure to adhere to Title 22 87303 and ensure the facilty is in good repair at all times. Stove burners and oven door must be repaired and an electrical wall cover must be placed to cover exposed wires. Proof of correction must be sent by POC due date: 09/11/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2023
LIC809 (FAS) - (06/04)
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