198205095-7-18-2024-11-AS-RCLD-D7AUZP-20240718160151

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198205095
Report Date: 07/18/2024
Date Signed: 07/18/2024 04:02:01 PM

Document Has Been Signed on 07/18/2024 04:02 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:	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: 6	DATE:	07/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:16 PM
MET WITH:	Administrator Antonia Dionisio		TIME COMPLETED:	04:15 PM

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On 07/18/24 at 1:16 PM, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced required – annual inspection and met with Administrator Antonia Dionisio. The facility is licensed for six residents and approved for two hospice residents. Bedroom #1 is approved for ambulatory only. Bedrooms 2, 3, and 4 are approved for non-ambulatory residents. Annual Fees are due 07/31/24.

The facility is a single story home located in a residential neighborhood. There are five (5) bedrooms, two (2) resident bathrooms, 1/2 bathroom, living room, dining room, kitchen, laundry area, and attached garage.

The Administrator accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed.

Residents' bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises.

Continue to LIC809-C.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SOUTH BAY RESIDENTIAL CARE HOME	FACILITY NUMBER: 198205095
	VISIT DATE: 07/18/2024

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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, hot water temperature properly measured at 120F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked.

Common areas were clean and clear of hazards, doorways were free of obstructions.

LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxics were kept in locked storage cabinet. First Aid kit was available. Administrator tested the carbon monoxide detector and smoke detectors in the house. Both devices were functional.

5 staff records were reviewed, 5 out of 5 staff records had required criminal record clearances or criminal record exemptions.

5 resident records were reviewed and, 5 out of 5 resident records had medical assessments and pre-appraisal or reappraisals. Two residents’ medication was reviewed.

Deficiencies are being cited based on record review in accordance with the California Code of Regulations, Title 22, see LIC809D. LPA did not observe the required (20) annual training hours for staff.

An exit interview was conducted and Plans of Correction developed. A copy of this report and appeals was discussed and left with Administrator Antonia Dionisio.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/18/2024 04:02 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: SOUTH BAY RESIDENTIAL CARE HOME	FACILITY NUMBER: 198205095
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above for four out of four staff members (S2, S3, S4, S5) which poses a potential safety risk to persons in care. LPA Cloyd did not observe 20 hours of annual training for staff.
	POC Due Date: 08/13/2024
	Plan of Correction
1 2 3 4	The Administrator will email 20 hours of annual training for S2, S3, S4, and S5 to regina.cloyd@dss.ca.gov. The Administrator will ensure that staff stay current on annual training requirements.

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) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

LIC809 (FAS) - (06/04)

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