198204907-8-9-2022-11-AS-DSEA-CH6428-20220809184244

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198204907
Report Date: 08/09/2022
Date Signed: 08/09/2022 06:43:06 PM

Document Has Been Signed on 08/09/2022 06:43 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	GREEN MEADOWS BOARD AND CARE 11		FACILITY NUMBER:	198204907
ADMINISTRATOR:	ELLEN CASTILLO		FACILITY TYPE:	740
ADDRESS:	1595 OAKHORNE DRIVE		TELEPHONE:	(310) 325-8883
CITY:	HARBOR CITY	STATE: CA	ZIP CODE:	90710
CAPACITY:	6	CENSUS: 4	DATE:	08/09/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Caregivers - Armando Erni and Radmar Vistar		TIME COMPLETED:	02:30 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 08/09/2022, Licensing Program Analyst (LPA) Don Senaha conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA was met by caregivers Armando Erni and Radmar Vistar and explained the purpose of today’s visit. The facility is licensed to serve six (6) elderly residents ages 60 and above. The facility has a hospice waiver for one (1) resident. The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident's rooms, one (1) staff room, two (2) bathrooms, living area, dining area, kitchen, and outside shaded patio area. All four (4) residents were in the facility at the time of the visit and zero (0) on hospice care. LPA and caregiver Armando Erni toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were operational. The water temperature did not meet Title 22 regulations and are cited on the D page. There is an attached garage accessible through the door prior to entering the facility or the front of the garage. There is also a refrigerator/freezer located in the back patio area for additional food storage. The washer and dryer are located in the garage next to the water heater. Evaluation Report Continues on LIC 809-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Don Senaha	TELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022

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 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GREEN MEADOWS BOARD AND CARE 11	FACILITY NUMBER: 198204907
	VISIT DATE: 08/09/2022

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
26
27
28
29
30
31
32

LPA observed the facility to be appropriately furnished at the time of visit. LPA observed cleaning supplies and toxins under the kitchen sink (see LIC 809D page). The kitchen was inspected and there is sufficient perishable and non-perishable food available and properly maintained. There are two (2) fire extinguishers fully charged with one in the garage and the other in the kitchen area. Smoke detectors and carbon monoxide were tested and operational. A review of Medication Administration Records (MAR) was maintained in order and accurate. There was a first aid kit available stored in the kitchen.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed all mandated inspection control posters were posted.

Advisory Notes – Three (3) Technical Assistance were issued, please see LIC9102-AN.

There were five (5) deficiencies cited during this inspection visit. See 809D page and Case Management D page.

An exit interview was conducted and a copy of this report was provided to caregiver Armando Erni.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Don Senaha	TELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022

LIC809 (FAS) - (06/04)

Page: 3 of 7

Document Has Been Signed on 08/09/2022 06:43 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GREEN MEADOWS BOARD AND CARE 11	FACILITY NUMBER: 198204907
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as the water measured 124.9 F in bathroom of room #4, 123.9 F in shared bathroom and 123.4 F in kitchen sink which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/10/2022
	Plan of Correction
1 2 3 4	Licensee immediately adjusted the water temperature via the water heater. LPA measured prior to departure and the water temperature now meets Title 22 regulations on 8/9/22.

Type A

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
1 2 3 4	Based on observation the licensee did not comply with the section cited above. There was scissors in the unlocked dish washer and in resident R1 room unlocked which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/10/2022
	Plan of Correction
1 2 3 4	Licensee immediately removed the scissors and locked it up with the other sharps on 8/9/22.

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: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Don Senaha	TELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022

LIC809 (FAS) - (06/04)

Page: 2 of 7

Document Has Been Signed on 08/09/2022 06:43 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GREEN MEADOWS BOARD AND CARE 11	FACILITY NUMBER: 198204907
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)(1)

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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. 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. There was rust remover under the kitchen sink unlocked which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/10/2022
	Plan of Correction
1 2 3 4	Licensee immediately removed the toxin and locked it up with the other toxins on 8/9/22.

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: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Don Senaha	TELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022

LIC809 (FAS) - (06/04)

Page: 7 of 7