198203919-8-1-2024-11-AS-MLEN-D7R232-20240801170137

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198203919
Report Date: 08/01/2024
Date Signed: 08/01/2024 05:01:46 PM

Document Has Been Signed on 08/01/2024 05:01 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	TLC GUEST HOME II		FACILITY NUMBER:	198203919
ADMINISTRATOR:	MUQEET "MD" DAABHOY		FACILITY TYPE:	740
ADDRESS:	28024 CALZADA DR.		TELEPHONE:	3105480898
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90275
CAPACITY:	6	CENSUS: 5	DATE:	08/01/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:03 AM
MET WITH:	Rino Santos, House Manager		TIME COMPLETED:	05:04 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 08/01/24, Licensing Program Analyst (LPA) Mario Leon conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with house manager, Rino Santos. LPA explained the purpose of today’s visit. The facility is licensed to operate for (6) non-ambulatory elderly adults ages 60 and above. The facility is approved for (2) hospice residents and the facility currently has (2) hospice residents in care. 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, a shaded outside seating area, with an attached garage. LPA 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, adequate lighting was provided, and storage for the resident's personal belongings was observed. During LPA's inspection, room #1 needs the window sill cleaned and sections of the blinds were observed to need repairs. Room #4's window screen, closest to the TV, needs to be re-screened and sections of the blinds were also observed to need repairs. Bed linens, comforters, and bath towels were adequately stocked during today's visit. Bathrooms were operational and no mold was observed in bathroom numbers one (#1) and two (#2) showers. Bathroom #1's screen is in need of cleaning/disinfection, as the screen was observed dirty. LPA observed cleaning solutions below the sink in bathroom #2. Water temperature was measured at 111.0 degrees F in the kitchen, 108.0 degrees F in bathroom #1 and 106.5 degrees F in bathroom #2. A comfortable temperature of 73.4 degrees F was maintained in the facility. LPA observed the facility to be fully furnished at the time of the visit. Storage areas for personal hygiene and sharp objects were observed to be appropriately stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was adequately maintained. A fire extinguisher was fully charged, with mandated yearly maintenance tag dated as 10/20/2023. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms were available for use and all mandated posters and files were posted. Report continues, see LIC809C.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024

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 08/01/2024 05:01 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: TLC GUEST HOME II	FACILITY NUMBER: 198203919
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

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
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in having stove's left rear burner remaining in disrepair which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/12/2024
	Plan of Correction
1 2 3 4	LPA and House Manager have agreed that the broken stove left rear burner remaining in disrepair. Facility will send video/photo evidence to LPA, via email at Mario.Leon@DSS.CA.GOV, on or prior to the POC due date which is 08/12/2024.

Type B

Section Cited

CCR

87303(c)

Maintenance and Operation

(c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation, the licensee did not comply with the section cited above in having screens in room #4 were observed to be in disrepair and the screen in bathroom #1 needing to be cleaned/sanitized. Furthermore, sections of the blinds in room #1 and room #4 were observed to be in disrepair which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/06/2024
	Plan of Correction
1 2 3 4	LPA and House Manager have agreed that the screen in room #4 will be replaced and screen in bathroom #1 will be cleaned/disinfected and that sections of the blinds in room #1 and room #4 will be replaced/repaired. Facility will send video/photo evidence to LPA, via email at Mario.Leon@DSS.CA.GOV, on or prior to the POC due date which is 08/06/2024.

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) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/01/2024 05:01 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: TLC GUEST HOME II	FACILITY NUMBER: 198203919
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

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
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in LPA's observation of "Tilex" and what appeared to be "Fabuloso" underneath the sink in bathroom #2, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/01/2024
	Plan of Correction
1 2 3 4	Cleaning solutions were relocated, without LPA's observation, while LPA was on-site.

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) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/01/2024 05:01 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: TLC GUEST HOME II	FACILITY NUMBER: 198203919
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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
1 2 3 4	Based on LPA's observation, the licensee did not comply with the section cited above in having numerous flies about the kitchen and dining room area of the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/06/2024
	Plan of Correction
1 2 3 4	LPA and House Manager have agreed that the facility will install a screen across the door leading to the attached garage in order to keep out future insects. Facility will send video/photo evidence to LPA, via email at Mario.Leon@DSS.CA.GOV, on or prior to the POC due date which is 08/06/2024.

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) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024

LIC809 (FAS) - (06/04)

Page: 4 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: TLC GUEST HOME II	FACILITY NUMBER: 198203919
	VISIT DATE: 08/01/2024

NARRATIVE

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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-#3 (S1-S3) personnel files appeared to be complete.

There have been four (4) deficiencies cited during today's visit, see LIC809D. There has been one advisory note provided, see LIC9102TV.

An exit interview was held with Rino Santos, House Manager, and a copy of the facilities' appeal rights and this report were provided.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024

LIC809 (FAS) - (06/04)

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