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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198205203
Report Date: 06/16/2023
Date Signed: 06/16/2023 03:25:11 PM


Document Has Been Signed on 06/16/2023 03:25 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:GLOBAL ELDERLY CARE FACILITY INC.FACILITY NUMBER:
198205203
ADMINISTRATOR:TERESITA CRUZ BAUTISTAFACILITY TYPE:
740
ADDRESS:2009 253RD PL.TELEPHONE:
(424) 250-9710
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY:6CENSUS: 6DATE:
06/16/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:TERESITA BAUTISTATIME COMPLETED:
03:45 PM
NARRATIVE
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On 6/16/2023, Licensing Program Analyst (LPA) Lourdes Montoya conducted a case management - deficiency visit.

During today's unrelated complaint visit, LPA observed the garage is full of clutters. LPA took photos of used clothes, lamps, boxes, black plastic bags, cardboards, old mattresses, etc. LPA observed the garage had molodorous smell.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8.

Exit interview conducted and a copy of the appeal rights were given at the time of the visit to Administrator Teresita Bautista.

SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2023
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 2


Document Has Been Signed on 06/16/2023 03:25 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: GLOBAL ELDERLY CARE FACILITY INC.
FACILITY NUMBER: 198205203

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/23/2023
Section Cited
CCR
87303(a)

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(a) 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 was not met as evienced by:
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Administrator shall ensure the garage is clean, in order and sanitary. Administrator agreed to clean the garage. POC shall be submitted to lourdes.montoya@dss.ca.gov by the POC due date.
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During an unrelated complaint visit, LPA observed the garage is full of clutters. LPA took photos of used clothes, lamps, boxes, black plastic bags, cardboards, old mattresses, etc. LPA observed the garage had molodorous smell. This poses a potetial health, safety and/or personal rights risk to residents in care.
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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: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2