198204651-8-9-2024-11-AS-WGIS-D7YUFZ-20240809153334

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198204651
Report Date: 08/09/2024
Date Signed: 08/09/2024 03:33:42 PM

Document Has Been Signed on 08/09/2024 03:33 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	HEARTS OF PARADISE HOME		FACILITY NUMBER:	198204651
ADMINISTRATOR:	BESSIE L COELLO		FACILITY TYPE:	740
ADDRESS:	4139 W. 177TH ST.		TELEPHONE:	(310) 371-7950
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90504
CAPACITY:	6	CENSUS: 6	DATE:	08/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:22 PM
MET WITH:	Ana Diaz		TIME COMPLETED:	03:45 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 08/09/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced annual visit to the facility listed above. LPA met with Direct Care Staff, Ada Diaz, and the purpose of today’s visit was explained. The facility is licensed to serve six (6) non-ambulatory residents over the age of 60. The facility has an approved hospice waiver for three (3). Physical Plant/Structure The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident rooms, 2 bathrooms, living room, dining room, kitchen, laundry area, detached garage, and outside shaded patio area. On the outside patio, LPA observed a table with umbrella and chairs available for resident use. LPA observed all walkways around the facility to be clean, clear, and free of obstructions, debris, and hazards. LPA did not observe any bodies of water on the premises. Bedrooms LPA inspected all resident rooms and observed the walls and floors to be in good repair. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. LPA observed all resident rooms had the required furniture including a bed, dresser, nightstand, storage space for personal belonging, and ample lighting. LPA observed all beds had the required linens including a mattress cover, fitted sheet, blanket, comforter, (1) Continued On LIC909-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024

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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HEARTS OF PARADISE HOME	FACILITY NUMBER: 198204651
	VISIT DATE: 08/09/2024

NARRATIVE

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and pillows. LPA observed an ample supply of bed linens, and comforters at the time of visit.
Bathrooms LPA inspected the facility bathrooms and found them to be within Title 22 regulations. All bathrooms were observed clean and operational. LPA observed storage area for personal hygiene products. LPA observed an ample supply of towels and personal hygiene products available for residents. All showers had a nonskid mat, shower chairs and secured safety handrails. The water temperature measured 116-degrees and 108.8-degrees Fahrenheit.
Kitchen LPA inspected the kitchen and observed it to be clean and sanitary. LPA observed all appliances to be operable and in good repair. LPA observed an ample supply of dishware, cookware, and cutleries. LPA observed a 3-day supply of perishable foods and a 7-day supply of non-perishable foods properly stored and labeled. The water temperature measured 112.3-degrees Fahrenheit. All sharps are secured in a locked cabinet and are inaccessible to residents. All cleaning supplies are secured in a locked cabinet under the kitchen sink and are inaccessible to residents.
Common Rooms LPA observed the facility to be appropriately furnished during the time of visit. The facility has a living room with recliners to accommodate all residents. The dining room table is large enough to accommodate residents for meals. LPA observed all walkways and hallways to be clean, clear, and free of hazards and obstructions. All rooms were observed with ample lighting. The facility was kept at a comfortable temperature.

(2) Continued On LIC809-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024

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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HEARTS OF PARADISE HOME	FACILITY NUMBER: 198204651
	VISIT DATE: 08/09/2024

NARRATIVE

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Safety LPA observed a fully charged fire extinguisher located in the kitchen, last serviced on 08/24/23. All smoke and carbon monoxide detectors are operable. The last emergency drill was conducted on 07/26/24. The last Fire Prevention Inspection was completed by the Torrance Fire Department on 02/13/24. All exits are indicated with an EXIT sign. The facility sketch is posted at the entrance of the facility. The facility’s Emergency and Disaster Plan is posted on a board at the entrance of the kitchen. LPA observed all required documents posted in the facility. The facility has a working landline telephone. There are no firearms are ammunition stored at the facility.
Medication LPA observed all Centrally Stored Medications secured in a locked cabinet, in the laundry room, and are inaccessible to residents. All medications were observed in their original packaging. LPA reviewed the medications and Medication Administration Record (MAR) for the three (3) residents. Three (3) out of three (3) resident’s MARs and medication are consistent with properly documented records.
Infection Control Upon entry, LPA observed a sanitizing station and visitor sign-in log. LPA observed on the table there is hand sanitizer and masks available. Upon entry, LPA was screened for Covid-19 symptoms and temperature was taken and recorded. LPA observed all staff wearing face masks. LPA reviewed the resident Daily Temperature Log. LPA observed all required Infection Control signs posted in the facility. LPA observed a 30-day supply of Personal Protective Equipment (PPE). LPA observed a PPE cart in the entrance of facility and in the bathroom.

(3) Continued On LIC809-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024

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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HEARTS OF PARADISE HOME	FACILITY NUMBER: 198204651
	VISIT DATE: 08/09/2024

NARRATIVE

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File Review LPA reviewed the files for the four (4) residents and observed they had the required documents. LPA reviewed the administrator and two (2) staff files and found they contained the required documents, certification, and training. LPA reviewed the Liability Insurance through Acord valid through 11/03/24. The administrator’s Administrator Certificate is valid through 01/04/25. During facility file review, LPA observed licensing fees were current.

LPA did not observe or cite any deficiencies.

An exit interview was conducted with Direct Care Staff, Ada Diaz, and a copy of this report was provided.

(4)

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024

LIC809 (FAS) - (06/04)

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