198205203-2-15-2024-11-AS-AINZ-D2GT8D-20240215133009

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198205203
Report Date: 02/15/2024
Date Signed: 02/15/2024 01:30:15 PM

Document Has Been Signed on 02/15/2024 01:30 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	GLOBAL ELDERLY CARE FACILITY INC.		FACILITY NUMBER:	198205203
ADMINISTRATOR:	TERESITA CRUZ BAUTISTA		FACILITY TYPE:	740
ADDRESS:	2009 253RD PL.		TELEPHONE:	(424) 250-9710
CITY:	LOMITA	STATE: CA	ZIP CODE:	90717
CAPACITY:	6	CENSUS: 6	DATE:	02/15/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	11:48 AM
MET WITH:	Maricel Querol/House Manager		TIME COMPLETED:	01:30 PM

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On 2/15/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Maricel Querol/ House Manager. LPA explained the purpose of today’s visit. Facility is licensed for (6) non-ambulatory residents and (1) bedridden resident. The facility has an approved hospice waiver for (4) residents.

The facility consists of (4) resident bedrooms, (3) bathrooms, living room, dining room, kitchen.

LPA Iniguez toured the physical plant with house manager. There were no bodies of water or obstructions on the premises. A total of (3) rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected the carbon monoxide detectors combo were in operable condition. The water temperature properly measured between: 105°F-120°F: Kitchen 111.1°F, Bathroom #1:110.7°F and Bathroom #2:113.7°F.

Evaluation Report Continues LIC 809-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: GLOBAL ELDERLY CARE FACILITY INC.	FACILITY NUMBER: 198205203
	VISIT DATE: 02/15/2024

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LPA Iniguez observed the facility to be clean, sanitary, and appropriately furnished at the time of the visit. Storage areas for personal hygiene were observed. Sharps objects and cleaning agents were locked and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available at the property. All fire extinguishers were charged and were operable. A review of (3) residents' service files, (3) staff personnel files were reviewed. LPA checked (3) Medication Administration Records (MAR) and no discrepancies were found. The first AID kit was checked. Last facility disaster drill was: 12/7/2023.

LPA observed the facility's infection control practices. A copy of the liability insurance will be email to LPA.

Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See details below:

-No updated LIC 602A for R#1 and R#3 on file.

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Maricel Querol /House Manager.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/15/2024 01:30 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: GLOBAL ELDERLY CARE FACILITY INC.	FACILITY NUMBER: 198205203
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and records review, the licensee did not comply with the section cited above in not having a recent LIC 602A for R#1 and R#3 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/27/2024
	Plan of Correction
1 2 3 4	Licensee will ensure all residents with dementia will have an updated LIC 602A on file. As part of plan of correction, licensee will get an updated LIC 602A for R#1 and R#3 then a copy of these will be email to LPA before POC due date.

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: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

LIC809 (FAS) - (06/04)

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