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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204998
Report Date: 04/25/2024
Date Signed: 04/30/2024 08:56:38 AM


Document Has Been Signed on 04/30/2024 08:56 AM - 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:ANZA HOME CAREFACILITY NUMBER:
198204998
ADMINISTRATOR:RODRIGO RAMOSFACILITY TYPE:
740
ADDRESS:19917 ANZA AVENUETELEPHONE:
(310) 370-9613
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY:6CENSUS: 4DATE:
04/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:12 AM
MET WITH:Patricia ChancoTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sparkle Day conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the one- year inspection. LPA met with staff Patricia Chanco, caregiver and spoke with Shalani Ramos via phone and the purpose of the visit was discussed. Ms. Ramos indicated that she is the Co-Administrator and is awaiting a new license including her name. The facility is licensed to serve 1 non- ambulatory residents age 60 and above and fire cleared for 5 bedridden residents and a hospice approved for 6 residents. The facility does not handle any of the residents’ money.

This home is a single story home consisting of: (6) resident bedrooms, (1) staff room (2) Full bathroom, living room, kitchen, dining area, laundry room (located in the attached garage) and an outdoor shaded patio area. LPA toured the 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 between 116.1F. 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. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

Deficiencies cited under California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiencies:

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Sparkle DayTELEPHONE: (424) 544-1075
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: ANZA HOME CARE
FACILITY NUMBER: 198204998
VISIT DATE: 04/25/2024
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-On 4/25/24 at 9:00 AM LPA reviewed resident records and observed that R#2 and R#3 did not have current physician reports. LPA asked Shalani Ramos about the records who indicated they are in the process of getting the physician reports.

On 4/24/2024 at 11:00 am LPA toured the backyard and found the ramp surrounding the home in poor condition. The Ramp has weak spots that were unsafe. LPA asked Shalani Ramos about the ramp and she indicated they are in the process of finding someone to replace the ramp.

On 4/24/2024 at 11:10 am LPA toured the inside of facility and observed that R#3 has full bed rails and is not a hospice residents. LPA asked Shalani Ramos regarding the rails and she indicated she has a doctors prescription for the rails but it is not in the residents file.

An exit interview was conducted and a copy of Report and Appeal Rights provided.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Sparkle DayTELEPHONE: (424) 544-1075
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/30/2024 08:56 AM - 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: ANZA HOME CARE
FACILITY NUMBER: 198204998

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care. Resident # 2 has full bedrails on bed and is not on hospice
POC Due Date: 05/02/2024
Plan of Correction
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Administrator agree to remove full bedrails or provide physicial prescription for rails by POC date. Administrator will send documentation to Sparkle.day@dss.ca.gov
Type B
Section Cited
CCR
87303(a)

The facility shall be clean , safe, sanitary, and in good repair at all times
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care. LPA Day toured the outside of the facility and found the ramp surrounding the rear of the home needs replacement and/ or repair due to old wood that has weak spots to walk on .
POC Due Date: 05/23/2024
Plan of Correction
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Administrator agrees to have ramp repaired and or replaced in all the weak wood and unsafe areas by POC date. LPA will make a visit to ensure ramp is safe by POC date.
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: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Sparkle DayTELEPHONE: (424) 544-1075
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 04/30/2024 08:56 AM - 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: ANZA HOME CARE
FACILITY NUMBER: 198204998

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(5)

Faciltiy residents with dementia shall have annual medical assessments
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care. Residents #2 and #3 did not have current medical assessment on file at time of visit.
POC Due Date: 05/10/2024
Plan of Correction
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Administrator agrees to have annual medical assessments for all residents with dementia. Medical Assessment will be sent to Sparkle.day@dss.ca.gov by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Sparkle DayTELEPHONE: (424) 544-1075
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4