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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204621
Report Date: 04/28/2023
Date Signed: 04/28/2023 04:04:20 PM

Document Has Been Signed on 04/28/2023 04:04 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:SEDONA GUEST HOMEFACILITY NUMBER:
198204621
ADMINISTRATOR:ANTONIO ARBOLEDAFACILITY TYPE:
740
ADDRESS:21635 HOWARD STREETTELEPHONE:
3107929020
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY: 6CENSUS: 4DATE:
04/28/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
08:47 AM
MET WITH:Nicanor Santos - CaregiverTIME COMPLETED:
04:33 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mario Leon conducted an unannounced Annual required inspection to the above facility. LPA was met by Jennifer Mape, Caregiver and was later met by Nicanor Santos, Senior Care Giver and the purpose of today’s visit was explained.

The facility is currently licensed to serve six (6) non-ambulatory residents, aged 60 years and above. There are currently four (4) residents in the facility. All (4) residents are non-ambulatory. The facility is a single story structure located in a residential neighborhood which consists of (6) bedrooms, (4) full bathrooms, shaded back yard, front yard and an attached 2-car garage which has a laundry room and staff sleeping room located inside.

LPA and Nicanor Santos toured the entire facility inside and out. Most documents are posted as mandated, missing PUB475. Bedrooms 1, 4 - 6 are occupied by residents and contain the mandated furniture. Rooms 2 and 3 are currently vacant. Resident in bedroom 1 is on oxygen and appropriate sign is present. The four (4) bathrooms are clean and operational. First aid kit is fully stocked with manual, smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water are present. Medications are stored, locked and inaccessible to residents. Residents Medications are current, resident paperwork needs upkeep. Staff file is current. Ample supply of perishable and nonperishable food, hot water temperature was measured at 134.2 degrees F, outside of Title 22 regulations. LPA observed linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items were accessible to residents, 1 fire extinguisher is fully charged, fire drill conducted on 04/2023 at 8:00AM. Exits, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility's walls and floors are in good working repair. During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry, visitors are logged with each visitors' temperature checked. Sanitizer/soaps are located in the all bathrooms and additional sanitation supplies are locked in the garage.

SEE LIC809-C

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 12
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: SEDONA GUEST HOME
FACILITY NUMBER: 198204621
VISIT DATE: 04/28/2023
NARRATIVE
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 LPA observed staff wearing masks, resident private rooms will be converted to isolation rooms (if needed) and required postings throughout the facility. The resident’s temperatures are checked and logged when necessary. PPE's are enough for 30 days.

According to the California Code of Regulations, LPA observed 12 citations. See LIC809-D. LPA observed two technical assistance notes, See LIC9102-AN.

An exit interview was conducted with Nicanor Santos, Senior Caregiver and copy of appeal rights, deficiencies, TA notes and report were provided to Nicanor Santos.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 12
Document Has Been Signed on 04/28/2023 04:04 PM - It Cannot Be Edited


Created By: Mario Leon On 04/28/2023 at 01:50 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SEDONA GUEST HOME
FACILITY NUMBER: 198204621

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2023

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
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2
3
4
Based on LPA's observations, the licensee did not comply with the section cited above in displaying cleaning solutions and knives available to residents in care which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2023
Plan of Correction
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2
3
4
Licensee will repair locks in the kitchen area as necessary to remain in state compliance. All maintenance will be documented in media evidence (PHOTO/VIDEO) and submitted to Mario.Leon@DSS.CA.GOV
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
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023


LIC809 (FAS) - (06/04)
Page: 3 of 12
Document Has Been Signed on 04/28/2023 04:04 PM - It Cannot Be Edited


Created By: Mario Leon On 04/28/2023 at 02:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SEDONA GUEST HOME
FACILITY NUMBER: 198204621

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on LPA's record review, the licensee did not comply with the section cited above in not providing liability insurance which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2023
Plan of Correction
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2
3
4
Licensee will update their insurance policy to remain in compliance with state licensing on, or prior to, the POC due date as listed above. All proofs will be submitted to Mario.Leon@DSS.CA.GOV
Alternatively, these documents may be dropped off, or mailed to, 1000 corporate center dr, STE100, Monterey Park, CA (attn: Mario)
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
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2
3
4
Based on LPA observation, the licensee did not comply with the section cited above in having a broken cabinet below the kitchen sink which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2023
Plan of Correction
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4
Licensee will repair the cabinet drawer below the kitchen sink, in the kitchen area, as necessary to remain in state compliance. All maintenance will be documented in media evidence (PHOTO/VIDEO) and submitted to Mario.Leon@DSS.CA.GOV
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
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023


LIC809 (FAS) - (06/04)
Page: 6 of 12
Document Has Been Signed on 04/28/2023 04:04 PM - It Cannot Be Edited


Created By: Mario Leon On 04/28/2023 at 02:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SEDONA GUEST HOME
FACILITY NUMBER: 198204621

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on LPA's measurement, the licensee did not comply with the section cited above in having the hot water at 134.2 degrees F which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2023
Plan of Correction
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Licensee will bring the hot water temperature down, to be within Title 22 regulations as shown above, throughout the house as necessary to remain in state compliance. All maintenance will be documented in media evidence (PHOTO/VIDEO) and submitted to Mario.Leon@DSS.CA.GOV
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on LPA's record review, the licensee did not comply with the section cited above in having missing resident documents: admission agreements with client signature, updated medical assessments, appraisal/needs & services plans as well as medical consent forms present which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2023
Plan of Correction
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Licensee will ammend resident paperworks as necessary to remain in state compliance. All files will be documented in media evidence (.doc, .docx or .pdf) and submitted to Mario.Leon@DSS.CA.GOV
Alternatively, these documents may be dropped off, or mailed to, 1000 corporate center dr, STE100, Monterey Park, CA (attn: Mario)
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
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023


LIC809 (FAS) - (06/04)
Page: 7 of 12
Document Has Been Signed on 04/28/2023 04:04 PM - It Cannot Be Edited


Created By: Mario Leon On 04/28/2023 at 02:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SEDONA GUEST HOME
FACILITY NUMBER: 198204621

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(10)
Resident Records
(b) Each resident's record shall contain at least the following information: (10) Reports of the medical assessment specified in Section 87458 Medical Assessment, and of any special problems or precautions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA's record review, the licensee did not comply with the section cited above in missing three (3) out of four (4) residents medical assessments which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2023
Plan of Correction
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2
3
4
Licensee will update resident's records as necessary to remain in state compliance. All files will be documented in media evidence (.doc, .docx or .pdf) and submitted to Mario.Leon@DSS.CA.GOV
Alternatively, these documents may be dropped off, or mailed to, 1000 corporate center dr, STE100, Monterey Park, CA (attn: Mario)
Type B
Section Cited
CCR
87506(b)(16)
Resident Records
(b) Each resident's record shall contain at least the following information: (16) Records of resident's cash resources as specified in Section 87217, Safeguards for Resident Cash, Personal Property, and Valuables.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA's record review, the licensee did not comply with the section cited above in missing two (2) out of four (4) residents safeguards for property values which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2023
Plan of Correction
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2
3
4
Licensee will update resident's records as necessary to remain in state compliance. All files will be documented in media evidence (.doc, .docx or .pdf) and submitted to Mario.Leon@DSS.CA.GOV
Alternatively, these documents may be dropped off, or mailed to, 1000 corporate center dr, STE100, Monterey Park, CA (attn: Mario)
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
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023


LIC809 (FAS) - (06/04)
Page: 8 of 12
Document Has Been Signed on 04/28/2023 04:04 PM - It Cannot Be Edited


Created By: Mario Leon On 04/28/2023 at 02:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SEDONA GUEST HOME
FACILITY NUMBER: 198204621

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's record review, the licensee did not comply with the section cited above in missing three (3) out of four (4) residents updated medical assessment paperwork which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2023
Plan of Correction
1
2
3
4
Licensee will update resident's records as necessary to remain in state compliance. All files will be documented in media evidence (.doc, .docx or .pdf) and submitted to Mario.Leon@DSS.CA.GOV
Alternatively, these documents may be dropped off, or mailed to, 1000 corporate center dr, STE100, Monterey Park, CA (attn: Mario)
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
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023


LIC809 (FAS) - (06/04)
Page: 9 of 12
Document Has Been Signed on 04/28/2023 04:04 PM - It Cannot Be Edited


Created By: Mario Leon On 04/28/2023 at 02:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SEDONA GUEST HOME
FACILITY NUMBER: 198204621

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.

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 lacking the above mentioned poster availability which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2023
Plan of Correction
1
2
3
4
Licensee will post the required poster as necessary to remain in state compliance. All maintenance will be documented in media evidence (PHOTO/VIDEO) and submitted to Mario.Leon@DSS.CA.GOV

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
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023


LIC809 (FAS) - (06/04)
Page: 10 of 12
Document Has Been Signed on 04/28/2023 04:04 PM - It Cannot Be Edited


Created By: Mario Leon On 04/28/2023 at 02:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SEDONA GUEST HOME
FACILITY NUMBER: 198204621

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

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 residents lacking physician orders for bed rails which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2023
Plan of Correction
1
2
3
4
Licensee will update resident's documentation as necessary to remain in state compliance. All files will be documented in media evidence (.doc, .docx or .pdf) and submitted to Mario.Leon@DSS.CA.GOV
Alternatively, these documents may be dropped off, or mailed to, 1000 corporate center dr, STE100, Monterey Park, CA (attn: Mario)
Type B
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's observation and record review the licensee did not comply with the section cited above in having two residents without having physician orders for postural supports which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2023
Plan of Correction
1
2
3
4
Licensee will update resident's documentation as necessary to remain in state compliance. All files will be documented in media evidence (.doc, .docx or .pdf) and submitted to Mario.Leon@DSS.CA.GOV
Alternatively, these documents may be dropped off, or mailed to, 1000 corporate center dr, STE100, Monterey Park, CA (attn: Mario)
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
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023


LIC809 (FAS) - (06/04)
Page: 11 of 12
Document Has Been Signed on 04/28/2023 04:04 PM - It Cannot Be Edited


Created By: Mario Leon On 04/28/2023 at 03:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SEDONA GUEST HOME
FACILITY NUMBER: 198204621

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.319(a)
Regulations
(a) A licensee of a facility that has internet service shall provide at least one internet access device, such as a computer, smart phone, tablet, or other device, that can support real-time interactive applications, is equipped with videoconferencing technology, including microphone and camera functions, and is dedicated for resident use.

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 not having a public device available for tele-health visits for residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2023
Plan of Correction
1
2
3
4
Licensee will maintain facility requirements as necessary to remain in state compliance. All documentation will be submitted in media evidence (photo/video, .doc, .docx., .pdf) and submitted to Mario.Leon@DSS.CA.GOV
Alternatively, copies of these documents may be dropped off, or mailed to, 1000 corporate center dr, STE100, Monterey Park, CA (attn: Mario)
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
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023


LIC809 (FAS) - (06/04)
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