198204276-5-1-2023-28-AS-LMOA-CRER5N-20230501124325

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198204276
Report Date: 05/01/2023
Date Signed: 05/01/2023 12:43:31 PM

Document Has Been Signed on 05/01/2023 12:43 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	MPS HOME II		FACILITY NUMBER:	198204276
ADMINISTRATOR:	MARIA TAVAREZ		FACILITY TYPE:	740
ADDRESS:	5404 PEARCE AVENUE		TELEPHONE:	(562) 572-9931
CITY:	LAKEWOOD	STATE: CA	ZIP CODE:	90712
CAPACITY:	4	CENSUS: 4	DATE:	05/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:29 AM
MET WITH:	Flormine Resurreccion - Licensee		TIME COMPLETED:	01:00 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	Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility using the CARE Tool. LPA Mora met with Flormine Resurreccion (Licensee) and explained the reason for the visit. The facility is licensed to serve four non-ambulatory elderly residents, ages 60 and over. Facility has a hospice waiver for two residents. The facility is operating within the scope of its license. 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 Flormine toured the facility and the following was observed: the front and backyard are well maintained. There are no pools or large bodies of water. 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 106.2 degrees F and 106.4 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. The fireplace is fenced. 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. P&I funds are locked and kept in the hallway closet. (Continued to LIC 809C)

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MPS HOME II	FACILITY NUMBER: 198204276
	VISIT DATE: 05/01/2023

NARRATIVE

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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 five staff. LPA reviewed P&I funds for all four clients with staff present. LPA observed administrator certificate for Maria D Tavarez – 6028010740 with an expiration date of 08/25/2023. LPA interviewed 2 residents and 2 staff.

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 were provided.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

LIC809 (FAS) - (06/04)

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