198205095-7-17-2023-11-AS-WGIS-CTTU4A-20230717151449

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198205095
Report Date: 07/17/2023
Date Signed: 07/17/2023 03:14:55 PM

Document Has Been Signed on 07/17/2023 03:14 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	SOUTH BAY RESIDENTIAL CARE HOME		FACILITY NUMBER:	198205095
ADMINISTRATOR:	ELVIRA DAVID		FACILITY TYPE:	740
ADDRESS:	2460 W. 229TH PLACE		TELEPHONE:	(310) 534-1953
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90501
CAPACITY:	6	CENSUS: 4	DATE:	07/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:26 AM
MET WITH:	Antonia Dionisio		TIME COMPLETED:	03:15 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 07/17/23, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced annual visit to the facility listed above. LPA met with Administrator, Antonia Dionisio, and the purpose of today's visit was explained. The facility is licensed for 6 resident's and approved for 2 Hospice residents. Currently there are 4 resident's living at the facility. Structure The facility is a single story home located in a residential neighborhood. There are five (5) bedrooms, two (2) resident bathrooms, 1 staff bathroom, living room, dining room, kitchen, laundry area, and attached garage. Physical Plant LPA inspected the physical plant. The front and back yard are landscaped and clean. There is a ramp at the entrance, at the back entrance, and on the side of the house for an easy exit. All walkways and exits on the side of the facility are clean, clear, and free of obstructions, hazards, and debris. There is a fireplace in the living room that is screened and inaccessible to residents. Bedrooms LPA inspected all five (5) bedrooms. LPA observed all rooms to have the required furniture including, bed, dresser, nightstand with lamp, chair, and ample storage space to keep personal belongings. Three (3) beds were observed to have half bed rails per physicians orders. All bedrooms were observed clean; walls and floors were in good repair. Bathrooms LPA inspected all bathrooms. The bathrooms were observed to be clean and in good repair. The faucets, toilets, and showers were fully operable. LPA observed a nonskid mat in the showers and a shower chair available for residents. Safety handrails were securely fastened. The water temperature in the bathrooms measured between 108.7- degrees and 110.9-degrees Fahrenheit. Linens & Hygiene All beds were observed to have the required linens including a mattress cover, fitted sheets, blankets, pillows, and comforters available. LPA observed an ample supply of linens and bath towels in the hallway cabinet. LPA observed an ample supply of incontinent care products for residents. LPA observed an ample supply of hygiene products stored in the cabinets in the bathroom and an additional supply in the hallway cabinet. CONTINUED ON LIC809-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SOUTH BAY RESIDENTIAL CARE HOME	FACILITY NUMBER: 198205095
	VISIT DATE: 07/17/2023

NARRATIVE

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Kitchen LPA inspected the kitchen and observed it to be clean and sanitary. LPA observed all cutluries, pots, and pans to be in good repair. All appliances were in good working repair. LPA observed a 3-day supply of perishable foods and a 7-day supply of non-perishable foods. All knives and sharps are secured in a locked drawer and are inaccessible to residents. All cleaning products are stored in locked cabinets in the laundry area. The water temperature measured 111.2- degrees Fahrenheit.
Common Rooms In the living room, LPA observed a couch and six (6) recliners for residents. LPA observed games and activities for residents. The dining room has a large rectangular table to accommodate all residents. All rooms were observed to have ample lighting. All walkways and hallways were clean, and clear of obstructions and hazards.
Medications LPA reviewed four (4) resident centrally stored medications. All medications are secured in a locked cabinet in the dining room. All medications were observed to be in their original containers. Staff document medication distribution on a Medication Administration Record (MAR).
Safety LPA observed a fully charged fire extinguisher last serviced on 09/18/22, mounted on the wall in the kitchen. The last emergency drill was conducted on 07/04/23. All smoke and carbon monoxide detectors were tested and are operable. LPA observed all required postings throughout the facility, including the facility sketch with exits and shut off valves. LPA inspected the First Aid kit and found it contained the required item and a manual. There is a working landline telephone. LPA reviewed and received a copy of the facilities Liability Insurance. All exits are clearly marked. There are no fire arms or ammunition stored on the premises.
Infection Control Upon entry LPA was screened for Covid-19 symptoms and temperature was taken. At the entry is a sanitizing station that consist of sign-in sheet, temperature log, hand sanitizer, and PPE's available. LPA reviewed the resident and staff daily temperature logs. LPA observed a 30-day supply of PPEs stored in a cabinet in the dining room. LPA observed infection control signs posted throughout the facility.
Files & Interviews LPA reviewed the Administrator file, LPA looked up Administrator Certificated which expires on 12/11/24. LPA reviewed two (2) staff files and found they have the required documents, certification, and have or are currently receiving the required training. LPA reviewed four (4) resident files and found they had the required documents. LPA interviewed three (3) staff and they were able to answer questions regarding resident care and resident personal rights. LPA interviewed two (2) residents who stated they were happy, treated with respect by staff, and receive the services to meet their needs.

No deficiencies were cited during today's visit.
An exit interview was conducted with Administrator, Antonia Dionisio, and a copy of this report was provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023

LIC809 (FAS) - (06/04)

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