198204907-12-17-2023-11-AS-ARID-CYLUYY-20231217150042

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198204907
Report Date: 12/17/2023
Date Signed: 12/17/2023 03:00:51 PM

Document Has Been Signed on 12/17/2023 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:	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:	12/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:24 AM
MET WITH:	Noemie Bunag		TIME COMPLETED:	03:30 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 12/17/23, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced annual required visit using the new CARE Inspection Tool. LPA was met by caregivers Carmencita Yap and Radmar Vistar and explained the purpose of today’s visit. Later was joined with Noemie Bunag. 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 Richard and caregiver Radmar Vistar 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 hot water temperature tested 107. 2F and 106. 5F. 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: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonine Richard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2023

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: GREEN MEADOWS BOARD AND CARE 11	FACILITY NUMBER: 198204907
	VISIT DATE: 12/17/2023

NARRATIVE

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LPA observed the facility to be appropriately furnished at the time of visit. 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.

There were two (2) deficiencies cited during this inspection visit.

An exit interview was conducted and a copy of this report and appeal rights were provided to administrator Noemie Bunag

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonine Richard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/17/2023 03:00 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, 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: 12/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above staff S1 missing TB test which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/29/2023
	Plan of Correction
1 2 3 4	The licensee will adhere to Title 22 Section 87411(f). Plan of correction is to be submit ta LPA via email to Antonine.Richard@dss.ca.gov

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: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonine Richard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/17/2023 03:00 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, 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: 12/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above staff S1, and S2 are missing the first aid certificate on file, which poses/posed a potential health, safety or personal rights risk to persons in care.,
	POC Due Date: 12/29/2023
	Plan of Correction
1 2 3 4	The licensee will adhere to Titled 22 Section 1569.618(c)(3). Plan of correction is for licensee to submit copies of the staff CPR's to LPA via emai. Antonine.Rchard@dss.ca.gov

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: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonine Richard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2023

LIC809 (FAS) - (06/04)

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