198205143-9-1-2023-11-AS-WGIS-CV9VZ3-20230901165204

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198205143
Report Date: 09/01/2023
Date Signed: 09/01/2023 04:52:10 PM

Document Has Been Signed on 09/01/2023 04:52 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:	MATER DEI CARE HOME		FACILITY NUMBER:	198205143
ADMINISTRATOR:	SHEVA LIM		FACILITY TYPE:	740
ADDRESS:	1625 MAPLE AVENUE		TELEPHONE:	(310) 212-1456
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90503
CAPACITY:	6	CENSUS: 2	DATE:	09/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:33 PM
MET WITH:	Sheva Lim		TIME COMPLETED:	05:00 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 09/01/23, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced annual visit to the facility listed above. LPA met with Administrator, Sheva Lim, and the purpose of today's visit was explained. There are 2 Resident's currently residing at the facility. Physical Plant The facility is a single-story home in a residential neighborhood. It consist of 4-resident bedrooms, 2 bathroom, living room, dining room, 1-staff room, and a detached garage. LPA and the Administrator toured the facility. The front yard and backyard were observed to be clean and landscaped. LPA observed an outside shaded area with a table and chairs available for resident use. All gates on the sides of the home open easily to exit. All walkways were clean, clear, and free of debris, hazards and obstructions. LPA did not observe any bodies of water. Bedrooms LPA inspected all resident rooms. All rooms were observed to have the required furniture including a bed, dresser, nightstand, chair, and ample storage space for residents personal belongings. All beds had the required linens including a fitted mattress cover, fitted sheets, blankets, comforter, and pillows. An adequate supply of linens was observed. LPA observed the bedrooms to be clean and in good repair. Bathroom LPA inspected the bathrooms and found they met Title 22 regulations. The bathrooms were fully operational. LPA observed the showers to be clean and clear of mold and mildew. The showers had nonskid mats, shower chair, and secured safety handrails. LPA observed an adequate supply of towels and hygiene products for residents. The water temperature measured 105.3-degrees and 105.7-degrees Fahrenheit. Kitchen LPA observed the kitchen to be clean and sanitary. All appliances including stove, oven, refrigerator, microwave, and dishwasher were in good working repair. LPA observed an adequate supply of cutleries, pots, and pans in good repair. LPA observed a 3- day supply of perishable foods and a 7- day supply of nonperishable foods. All sharps are secured in a locked lock box in the kitchen and are inaccessible to residents. Cleaning supplies are secured in a locked cabinet in the laundry area and are inaccessible to residents. The water temperature measured 105.8-degrees Fahrenheit.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

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: MATER DEI CARE HOME	FACILITY NUMBER: 198205143
	VISIT DATE: 09/01/2023

NARRATIVE

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Common Rooms The living room has two long and a short couch, that accommodate all residents. LPA observed a fireplace that was covered and inaccessible to residents. The dining room has a long rectangle table and chairs to accommodate all residents. LPA observed all walkways and hallways in the facility to be clean and free of obstructions or hazards. All common rooms have adequate lighting. The facility was maintained at a comfortable temperature.
Safety LPA observed smoke detectors in all rooms that are fully operational. LPA observed a carbon monoxide detector. LPA observed a fully charged fire extinguisher by the front door, that was last serviced on 09/09/22. The last emergency drill was conducted on 07/10/23. All emergency personnel numbers were posted. The facility has a working landline telephone. On a wall in the living room and hallway, LPA observed all required posting including the Emergency and Disaster Plan, License, Licensing reports, Personal Rights, Nondiscrimination Notice, Complaint Information, Long-Term Ombudsman, and Theft and Loss Policy.
Medications LPA reviewed the medications and medication administration record (MAR) for all residents. LPA observed the medications in their original packaging. The medication is consistent with the MARs. Medications are secured in locked cabinet in the kitchen and are inaccessible to residents.
File Review & Interviews LPA reviewed all resident files and found it contained the required documents. LPA interviewed residents, and they were all happy with the care and services they receive at the facility. LPA reviewed the Administrator, and 2 staff files and found they contained the required certification, training, and documents. LPA interviewed staff that was at the facility, and they were able to answer questions regarding personal rights, care, policy, and procedure.

Infection control LPA observed a sanitizing station, visitor sign-in and log, at the entrance of the facility. LPA observed a 60-day supply of PPEs. LPA observed infection control signs posted throughout the facility.

During today's visit no deficiencies were observed or cited.

An exit interview was conducted with Administrator Sheva Lim, 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: 09/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

LIC809 (FAS) - (06/04)

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