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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204739
Report Date: 04/05/2024
Date Signed: 04/05/2024 01:07:07 PM


Document Has Been Signed on 04/05/2024 01:07 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:TLC GUEST HOME 1FACILITY NUMBER:
198204739
ADMINISTRATOR:TERESITA L. CASTANEDAFACILITY TYPE:
740
ADDRESS:18309 FAIRVIEW LANETELEPHONE:
(310) 819-3965
CITY:TORRANCESTATE: CAZIP CODE:
90504
CAPACITY:6CENSUS: 6DATE:
04/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Cristina StoDomingoTIME COMPLETED:
01:30 PM
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On 04/05/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced annual visit to the facility listed above. LPA met with Caregiver, Cristina StoDomingo, and the purpose of today’s visit was explained. The facility is licensed for 6 non-ambulatory residents over the age of 60, with a hospice waiver for 6 residents. Currently six (6) residents reside at the facility, and all six (6) were present during the visit.

Physical Plant/Structure The facility is a single-story home in a residential neighborhood. The facility consists of six (6) resident bedrooms, five (5) bathrooms, living room, dining room, kitchen, and garage. LPA toured the inside and outside of the facility. The front yard was observed to be landscaped and well maintained. The backyard has a covered patio with a large table and chairs to accommodate all residents. An additional table and chair are under the shade of a tree. The backyard is landscaped and well maintained. LPA observed all walkways around the home to be clean, clear, and free of debris, obstructions, and hazards. LPA did not observe any bodies of water on the premises.

Continued on LIC809-C

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024
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: TLC GUEST HOME 1
FACILITY NUMBER: 198204739
VISIT DATE: 04/05/2024
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Bedrooms LPA inspected all bedrooms and observed them to be clean and in good repair. All bedrooms had the required furniture including a bed, dresser, nightstand, chair, storage space for personal belongings, and ample lighting. All beds were observed to have the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. LPA observed and additional supply of linens in a cabinet in the hallway.

Bathrooms LPA inspected all bathrooms and found them to be clean and operational. All showers were observed to be clean and free of mildew and mold. All showers had a nonskid mat, shower chairs, and secured safety handrails. LPA observed an ample supply of hygiene products and incontinent care products for residents. LPA observed an ample supply of towels, hand towels and wash cloths in the cabinet in the hallway. The water temperature in the bathrooms measured between 111.9-degrees and 119.7-degrees Fahrenheit.

Kitchen LPA inspected the kitchen and found it to be clean and sanitary. LPA observed all appliance to be in good repair and operational. LPA observed a 3-day supply of perishable foods and a 7-day supply of nonperishable foods properly packaged, labeled, and dated. LPA observed an ample supply of cookware, dishware, and cutleries. LPA observed all knives and sharps secured in a locked drawer in the kitchen and are inaccessible to residents. LPA observed all cleaning supplies secured in a locked cabinet under the kitchen sink and are inaccessible to residents. The water temperature measured 107.3-degrees Fahrenheit.

Continued on LIC809-C

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024
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: TLC GUEST HOME 1
FACILITY NUMBER: 198204739
VISIT DATE: 04/05/2024
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Common Rooms LPA observed a couch and recliners in the living room, to accommodate residents. LPA observed books, magazines, games, and activities in the living room. The dining room has a long rectangular table with chairs to accommodate all residents. LPA observed all rooms to have ample lighting. All walkways and hallways in the facility were observed to be clean, clear, and free of obstructions and hazards.

Safety LPA observed a fully charged fire extinguisher in the kitchen that was last serviced on 09/20/23. All smoke and carbon monoxide detectors are operable. The facility’s last inspection by the Torrance Fire Department Fire Inspector was on 06/23/23. LPA observed all exits clearly marked. The last emergency drill was conducted on 01/05/24. LPA inspected the First Aid kit and observed it contained the required items and a manual. The facility has a working landline telephone. The facility sketch is posted in the dining room. LPA observed all required documents including emergency numbers and the facilities Emergency and Disaster Plan posted in the facility. When doors leading to the outside of the facility are opened an audio signal is produced. There are no security bars over the windows. There are no firearms or ammunition stored on the premises.

File Review/Interviews LPA reviewed six (6) resident files and found they contained the required documents. LPA interviewed five (5) residents who stated they were happy with the care and services they receive at the facility. LPA reviewed the files for the administrator and three (3) staff files and found they contained the required documents, certification, and training. The Administrator

Cotinued on LIC809-C

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024
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: TLC GUEST HOME 1
FACILITY NUMBER: 198204739
VISIT DATE: 04/05/2024
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Certificate is valid till 09/17/25. LPA interviewed two (2) staff who were able to answer questions regarding policy, procedure, and resident care. LPA informed staff the facility’s Licensing Fees are due on 05/07/24. LPA provided staff with the amount owed and the PIN for online payment.

Medications LPA observed medications secured in a locked cabinet in the dining room and are inaccessible to residents. LPA observed all medications to be in their original packaging. LPA reviewed residents Medication Administration Records (MARs) and medications for all residents. LPA observed six (6) out of six (6) resident’s MARs and medication are consistent with properly documented records.

Infection Control LPA observed a sanitizing station at the entrance at the facility. It has a visitor log, hand sanitizer, and a thermometer. LPA observed infection control signs posted throughout the facility. LPA observed a 90-day supplies of Personal Protective Equipment (PPE) stored in the garage. LPA observed an ample supplies of hand soap, paper towels, and cleaning supplies stored in the garage.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe or cite any deficiencies during today’s visit.

An exit interview was conducted with Caregiver, Cristina StoDomingo, and a copy of this report was provided.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024
LIC809 (FAS) - (06/04)
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