198204800-11-7-2024-11-AS-PSCT-DASVH2-20241107152625

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198204800
Report Date: 11/07/2024
Date Signed: 11/07/2024 03:26:35 PM

Document Has Been Signed on 11/07/2024 03:26 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	MY MOTHER'S PLACE		FACILITY NUMBER:	198204800
ADMINISTRATOR/ DIRECTOR:	HILDA LOZANO		FACILITY TYPE:	740
ADDRESS:	11827 ROSE AVENUE		TELEPHONE:	(310) 707-7768
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90066
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 3	DATE:	11/07/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:34 PM
MET WITH:	Rosa Pioquinto		TIME VISIT/ INSPECTION COMPLETED:	03:30 PM

NARRATIVE

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On 11/7/24, at 1:30pm, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced visit to My Mother’s Place. The purpose of today’s visit was to conduct the required annual inspection, using the new Care Tool. LPA was met by Rosa Pioquinto, staff, and the purpose of today’s visit was explained. The facility is licensed to serve six (6) non-ambulatory residents aged 60 and over. Currently, the home has (3) residents in care. The facilities’ annual fees are current.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) resident bedrooms, one (1) staff bedroom, three (3) bathrooms, living room, dining area, kitchen, laundry room, backyard patio, and a garage.

LPA could not conduct a records review because the resident and staff files were not available. LPA could not a medication review because the Medication Administration record was not available for review. LPA could not verify that an emergency drill was done because the records were not available for review. LPA could not verify the staff roster nor resident roster because the facility records were not available for review. Deficiencies were cited during the inspection.

At 1:50pm, LPA and staff toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All resident rooms were checked. Beds and bedding were in good condition, adequate lighting provided, adequate storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations. Toilets and water faucets worked properly. The shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature measured 108.5F. A comfortable temperature is maintained in the facility.

Report continued on LIC809-C

Janae Hammond	TELEPHONE: (424) 544-1027
Perry Scott	TELEPHONE: (707) 849-2315
	DATE: 11/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024

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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Document Has Been Signed on 11/07/2024 03:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: MY MOTHER'S PLACE	FACILITY NUMBER: 198204800
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. The licensee did not ensure that facility records were available for review upon annual inspection, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/21/2024
	Plan of Correction
1 2 3 4	The licensee will ensure that facility records are made available for review upon annual inspection. LPA will return for a case management visit.

Section Cited

Incidental Medical and Dental Care Services

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above because the licensee did not ensure that facility records were available for review upon annual inspection, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/21/2024
	Plan of Correction
1 2 3 4	The licensee will ensure that facility records are made available for review upon annual inspection. LPA will return for a case management visit.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Janae Hammond	TELEPHONE: (424) 544-1027
Perry Scott	TELEPHONE: (707) 849-2315
	DATE: 11/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024

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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: MY MOTHER'S PLACE	FACILITY NUMBER: 198204800
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Resident Records

(b) Each resident's record shall contain at least the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above because the licensee did not ensure that facility records were available for review upon annual inspection, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/21/2024
	Plan of Correction
1 2 3 4	The licensee will ensure that facility records are made available for review upon annual inspection. LPA will return for a case management visit.

Section Cited

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above because the licensee did not ensure that facility records were available for review upon annual inspection, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/21/2024
	Plan of Correction
1 2 3 4	The licensee will ensure that facility records are made available for review upon annual inspection. LPA will return for a case management visit.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Janae Hammond	TELEPHONE: (424) 544-1027
Perry Scott	TELEPHONE: (707) 849-2315
	DATE: 11/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/07/2024 03:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: MY MOTHER'S PLACE	FACILITY NUMBER: 198204800
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Other Provisions

(e) A facility shall have all of the following information readily available to facility staff during an emergency: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above because the licensee did not ensure that facility records were available for review upon annual inspection, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/21/2024
	Plan of Correction
1 2 3 4	The licensee will ensure that facility records are made available for review upon annual inspection. LPA will return for a case management visit.

Section Cited

Other Provisions

(e) A facility shall have all of the following information readily available to facility staff during an emergency: (1) A resident roster with the date of birth for each resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above because the licensee did not ensure that facility records were available for review upon annual inspectionin, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/21/2024
	Plan of Correction
1 2 3 4	The licensee will ensure that facility records are made available for review upon annual inspection. LPA will return for a case management visit.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Janae Hammond	TELEPHONE: (424) 544-1027
Perry Scott	TELEPHONE: (707) 849-2315
	DATE: 11/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/07/2024 03:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: MY MOTHER'S PLACE	FACILITY NUMBER: 198204800
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Other Provisions

(e) A facility shall have all of the following information readily available to facility staff during an emergency: (3) A resident medication list for residents with centrally stored medications. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above because the licensee did not ensure that facility records were available for review upon annual inspection, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/21/2024
	Plan of Correction
1 2 3 4	The licensee will ensure that facility records are made available for review upon annual inspection. LPA will return for a case management visit.

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.

Janae Hammond	TELEPHONE: (424) 544-1027
Perry Scott	TELEPHONE: (707) 849-2315
	DATE: 11/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024

LIC809 (FAS) - (06/04)

Page: 5 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: MY MOTHER'S PLACE	FACILITY NUMBER: 198204800
	VISIT DATE: 11/07/2024

NARRATIVE

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LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is enough perishable and non-perishable food available, which is stored properly. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The fire extinguishers were charged and last inspected on 8/22/2024. Smoke/ Carbon Monoxide detectors were operable.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents. LPA observed that sanitizing stations were in common areas and restrooms. LPA observed that the facility had the required postings, posted throughout the facility. LPA further observed the facility to have a 90-day supply of Personal Protective Equipment (PPE).

LPA advised the administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing (www.cdss.ca.gov) for Provider Informational Notices (PIN) and for any updates relating to COVID-19 guidance and other related issues.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did observe deficiencies during the visit.

Citations were issued during the annual inspection, and are listed on LIC9099-D.

An exit interview was held, and a copy of the Facility Evaluation Report was provided Rosa Pioquinto, staff.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (707) 849-2315
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024

LIC809 (FAS) - (06/04)

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