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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198205095
Report Date: 06/25/2021
Date Signed: 07/01/2021 08:31:02 AM

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
MONTERY PARK, CA 91754
FACILITY NAME:SOUTH BAY RESIDENTIAL CARE HOMEFACILITY NUMBER:
198205095
ADMINISTRATOR:ELVIRA DAVIDFACILITY TYPE:
740
ADDRESS:2460 W. 229TH PLACETELEPHONE:
(310) 534-1953
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY:6CENSUS: 5DATE:
06/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:46 PM
MET WITH:ANTONIA DIONISOTIME COMPLETED:
04:00 PM
NARRATIVE
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On 6-25-21 at 1:00 pm, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA Montoya called Administrator Antonia Dionisio and conducted a risk assessment over the telephone. Based on the assessment, the facility is clear of Covid-19 infection. LPA verified that the facility has an approved mitigation plan report.

The facility is licensed for three (3) ambulatory and three (3) non-ambulatory. Hospice waiver approved for two (2) residents.

At around 1:10 pm, LPA met with the House Manager, Perlita Abilar and they both toured the inside and outside grounds of the facility. LPA was properly screened for Covid-19 symptoms and temperature was checked. Administrator Antonia Dionisio arrived shortly and assisted LPA with the visit.

During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance; visitors log with Covid-19 screening and temperature log, and records of daily Covid-19 screening and temperature checks of residents. PPE supplies are readily available to staff, and an additional 30-day supply of PPE is stored in the garage; sufficient paper, cleaning, and disinfecting supplies were observed. The facility’s designated visitation area is the resident’s bedroom and living room. LPA observed staff and residents maintain 6 feet physical distancing, and each person wears a face covering. LPA observed required postings throughout the facility.

At around 2:12 pm, LPA reviewed the facility’s surveillance testing records, all staff are tested once every month. All staff and three out of five residents have been vaccinated. None of staff has completed the N-95 fit testing requirement. Covid-19 Infection Control and Prevention training records and in-service training on the approved mitigation plan were reviewed.

REPORT CONTINUED IN LIC 809C

SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
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
MONTERY PARK, CA 91754

FACILITY NAME: SOUTH BAY RESIDENTIAL CARE HOME
FACILITY NUMBER: 198205095
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(a)
Prior to construction or alteration, all facilities shall obtain a building permit.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation and innterview, the licensee did not comply with the section cited above. There is an ongoing exterior painting job in the facility. The entire exterior of the home and walkways have been painted. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2021
Plan of Correction
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Licensee shall submit a notification letter to CCLD explaining the details of the construction and how residents will be handled to ensure their personal rights, safety and health are not at risk. Licensee shall obtain approval prior to resuming any constuction work.
Type B
Section Cited
CCR
87307(d)(6)
The following space and safety provisions shall apply to all facilities: (6) All ourdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation and interview, the licensee did not comply with the section cited above. Passageways obstructions such a laundry bucket, hampers, laundry soap bucket, round table, cart, empty water and soda bottles in plastic bags, old mattress and other miscellaneous items were observed all around the outdoor passageways and stairways. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2021
Plan of Correction
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Licensee agreed to remove all obstructions out of the outdoor passageways and stairways of the facility by the POC due date. Licensee will email a proof of correction to CCLD by the POC due 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: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:
DATE: 06/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2021
LIC809 (FAS) - (06/04)
Page: 3 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
MONTERY PARK, CA 91754
FACILITY NAME: SOUTH BAY RESIDENTIAL CARE HOME
FACILITY NUMBER: 198205095
VISIT DATE: 06/25/2021
NARRATIVE
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All rooms were inspected. Beds in shared bedrooms are 6 feet apart/3 feet head-to-toe apart. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed.

Furniture in the living room are marked or separated, and 6 feet apart from each other. There are no security bars or weapons on the premises. Resident bathrooms were checked, sufficient liquid soap and paper towels were observed. Toilets and water faucets worked properly, grab bars were secure, the shower was free of mold/mildew, and a non-skid mat was in place. The water temperature measured at 117.4 degrees F. A comfortable temperature was maintained in the facility. All bedrooms and living room have smoke detectors and they are all operational. One operable carbon monoxide was observed.

LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in a locked storage cabinet. The First Aid kit was available. One fire extinguisher last serviced 3/4/2021 is fully charged. Outside grounds were toured, and no bodies of water were observed.

LPA observed the following deficiencies:

1. Outdoor chairs are not in good repair.

2. Obstructions in outdoor walkways

3. Ongoing construction which includes painting of the entire exterior part of the home and walkways.

4. Staff #1 is not associated to the facility.

Advisory Notes were issued, and Technical Assistance was provided.

Deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted and appeal rights discussed. A copy of this report and appeal rights provided to Administrator Antonia Dionisio.

SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
LIC809 (FAS) - (06/04)
Page: 5 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
MONTERY PARK, CA 91754

FACILITY NAME: SOUTH BAY RESIDENTIAL CARE HOME
FACILITY NUMBER: 198205095
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, record review and interview, Staff #1 is not associated to the facility according to LIS personnel summary records. Per administrator, staff #1 is working only as a trainee. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2021
Plan of Correction
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Licensee shall submit a request to transfer Staff #1's criminal record to the facility by the POC due 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: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:
DATE: 06/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2021
LIC809 (FAS) - (06/04)
Page: 7 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
MONTERY PARK, CA 91754

FACILITY NAME: SOUTH BAY RESIDENTIAL CARE HOME
FACILITY NUMBER: 198205095
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, patio chairs are not in good repair. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2021
Plan of Correction
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Licensee agreed to discard all patio chairs in disrepair and replace with chairs in good repair by the POC due date. Licensee will submit a proof of correction to CCLD by the POC due date.
Type B
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above. LPA observed and took photos of the following resident's medications: 2 bottles of generlac solutions, clearlax powder and metamucil on the kitchen counter. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2021
Plan of Correction
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Licensee moved the resident's medications into a locked cabinet during the 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.
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:
DATE: 06/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2021
LIC809 (FAS) - (06/04)
Page: 2 of 7