198204276-5-18-2024-28-AS-THEA-D5DVA4-20240518161520

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198204276
Report Date: 05/18/2024
Date Signed: 05/18/2024 04:16:06 PM

Document Has Been Signed on 05/18/2024 04:16 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:	05/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:48 PM
MET WITH:	Marie Resurreccion - Administrator		TIME COMPLETED:	04:25 PM

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Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced met with John L. Fernandez (Caregiver) and Belma Fernandez (Caregiver) [assistant administrator Marie Resurreccion arrived shortly after to assist with the visit], the purpose for today’s visit was explained. The facility is licensed to serve 4 non-ambulatory residents ages 60 and above, with a hospice waver for two. The facility currently has 4 residents all serviced through Harbor Regional Center, none of the residents are currently using hospice service.

The facility is a single-story home located in Lakewood, Ca. A tour of the facility includes: living room, dining area, kitchen, 4 resident bedrooms, 2 resident bathrooms, 1 staff bedroom with private bathroom, laundry area, attached garage, front yard and back yard.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit todays visit and the initial visit and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents’ medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility.
Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with required Infection Control Plan and facility maintains the required liability insurance.
Physical Plant & Environment Safety: LPA toured facility, residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The front yard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested throughout the facility and measured within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked and are inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable and in compliance.There fire extinguisher was observed and is fully charged.(continued on 809-C)

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2024

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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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: 05/18/2024

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Staffing: There appears to be sufficient staffing at all times in the facility. With night staff (live in staff) that are trained and able to assist in care and supervision of the residents in the case of an emergency.
Personnel Records-Training: Staff has criminal record clearance, current First-Aid/CPR/AED training along with training in postural supports, medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 5 staff files with no issues observed. Administrator Richardo Banos certificate expires on 1/11/25.
Resident Records-Incident Reports: Resident files are kept in a secure location and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 4 Resident Files with no issues observed.
Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman.
Planned Activities: Facility provides scheduled activities and have a variety of activities to choose from within the facility. There is an outdoor activity area available for the residents.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Incidental Medical & Dental: Medication is properly labeled and are centrally stored in a closet and are in their original containers. LPA reviewed 4 residents’ medications and there were no issues observed.
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Last fire/disaster/earthquake drill was conducted on 4/2/24.
Residents with Special Health Needs: There are no bedridden or residents with postural supports at this facility.

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 was emailed to Marie Resurreccion.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2024

LIC809 (FAS) - (06/04)

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