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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204276
Report Date: 04/26/2022
Date Signed: 04/26/2022 01:52:59 PM


Document Has Been Signed on 04/26/2022 01:52 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:MPS RETIREMENT HOMEFACILITY NUMBER:
198204276
ADMINISTRATOR:MARIA TAVAREZFACILITY TYPE:
740
ADDRESS:5404 PEARCE AVENUETELEPHONE:
(562) 572-9931
CITY:LAKEWOODSTATE: CAZIP CODE:
90712
CAPACITY:6CENSUS: 4DATE:
04/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:51 PM
MET WITH:Belma Fernandez - CaregiverTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility with focus on the infection control domain, medication and food review. LPA Mora met with Caregiver Belma Fernandez and explained the reason for the visit. The Licensee Flormine Resurreccion showed up shortly after. The facility is licensed to serve six non-ambulatory elderly residents, ages 60 and over. Facility has a hospice waiver for two residents. The facility is located in a residential area. A tour of the single-story facility included: living room, kitchen, dining area, 4 resident bedrooms, 1 staff bedroom, 2 bathrooms, laundry room, front yard, backyard and attached garage.

LPA and Belma Fernandez toured the facility and the following was observed: the front and backyard are well maintained. There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction. Auditory devices were seen on all exit doors which are required for dementia residents and were operating at the time of the visit. The water temperature was tested in both bathrooms and measured at 106 degrees F and 106.8 degrees F which is within the required 105 - 120 degrees F. The bathrooms are clean and have the required grab bars in the shower and near the toilet for non-ambulatory residents. Showers also have non-skid materials. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have enough closet space. Resident beds have the required linen and the linen is in good condition. There is extra clean linen and towels in a hallway closet. Smoke detectors were observed in each room and throughout the facility and are properly operating. There is one carbon monoxide in the hallway and is properly operating. There are 2 fire extinguishers located in the living room and near the back exit door, which are fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps, cleaning supplies and toxins are kept locked under the kitchen sink and are inaccessible to residents. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen and garage. First Aid kit was fully stocked with current manual and it is kept locked in a cabinet located in the dining area. Residents medication are centrally stored in a locked cabinet in the dining area. Residents and staff files are centrally stored in a hallway closet. (CONTINUED TO LIC 809C)

SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2022
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MPS RETIREMENT HOME
FACILITY NUMBER: 198204276
VISIT DATE: 04/26/2022
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LPA reviewed medication for all four of the residents and observed that medications are documented properly and given as prescribed. LPA reviewed files for all four residents and two staff and observed no issues with the files. LPA observed administrator certificate for Maria D Tavarez – 6028010740 with an expiration date of 08/25/2023.

Facility is following COVID 19 recommendations regarding screening visitors, staff, and residents. Signs are posted throughout the facility, and hand-washing signs were observed in bathroom. Sufficient hand soap, hand sanitizer, and paper towels were observed. Supply of 30-day Personal Protective Equipment (PPE) was observed in the living room and garage.



Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022
LIC809 (FAS) - (06/04)
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