198204651-12-27-2023-11-AS-EGOZ-CYWUYG-20231227145955

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198204651
Report Date: 12/27/2023
Date Signed: 12/27/2023 03:00:02 PM

Document Has Been Signed on 12/27/2023 03:00 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:	12/27/2023
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	11:55 AM
MET WITH:	Bessie Coello		TIME COMPLETED:	03:10 PM

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Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced annual required visit to the above facility. LPA met with house manager Ada Diaz and the purpose of the visit was discussed. Administrator Bessie Coello joined LPA to conduct the visit shortly after. LPA was granted access to the facility. Facility is licensed to serve six (6) non-ambulatory residents aged 60 and over. This facility has an approved hospice waiver for three (3) residents. The facility currently has six (6) residents.

The facility is a single-story structure located in a residential neighborhood. It consists of (4) bedrooms, (2) bathrooms, living room, kitchen, dining room, laundry area, an outdoor shaded patio area, and a detached garage.

LPA and Administrator toured the entire facility inside and out. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured at 110.4 F in bathroom (1) and at 113.3 F in bathroom (2). Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions.

Kitchen was checked and observed to be within Title 22 regulations. Sufficient perishable and non-perishable food supply was maintained adequately. All sharps, toxins, cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. A review of Medication Administration Records was maintained in order and accurate. The facility has a landline telephone on-site in working condition. Medications were centrally stored and properly locked. Smoke detectors and carbon monoxide detectors were operational and working properly.

Continued on LIC 809-C

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elvira Gonzalez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

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

FACILITY NAME: HEARTS OF PARADISE HOME	FACILITY NUMBER: 198204651
	VISIT DATE: 12/27/2023

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Fire extinguisher was fully charged. A stocked First Aid kit along with manual was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards.

During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents. There are sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has an approved CCLD Mitigation Plan.

During this inspection LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview was conducted, and a copy of Report and Appeal Rights was provided to house manager Ada Diaz.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elvira Gonzalez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

LIC809 (FAS) - (06/04)

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