198205247-3-2-2022-11-AS-EDAT-CC69D9-20220302221622

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198205247
Report Date: 03/02/2022
Date Signed: 03/02/2022 10:17:13 PM

Document Has Been Signed on 03/02/2022 10:17 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME:	SOUTH BAY RESIDENTIAL HOME		FACILITY NUMBER:	198205247
ADMINISTRATOR:	EDITHA A. PACLEB		FACILITY TYPE:	740
ADDRESS:	430 WEST 214TH STREET		TELEPHONE:	(424) 271-7310
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY:	6	CENSUS: 6	DATE:	03/02/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:04 PM
MET WITH:	Edith Pacleb		TIME COMPLETED:	03:23 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 03/02/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with licensee Edith Pacleb and explained the purpose of today’s visit. The facility is licensed to operate for (6) non-ambulatory elderly residents ages 60 and above. The facility is approved for (1) hospice resident. The facility is a single-story structure located in a residential neighborhood. It consists of the following: (4) residents' rooms, (2) common bathrooms, living area, dining area, kitchen, and outside covered patio area. LPA and licensee toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 118.8 F. A comfortable temperature of 74 degrees was maintained in the facility. LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. The facility has(1) fire extinguisher that was charged, smoke detectors, and carbon monoxide were operable. LPA reviewed Medication Administration Records (MAR) revealed accurate and maintained in order. The facility conducted a Fire/Safety Drill on 02/22/22. A working landline telephone remains available. Evaluation Report Continues on LIC 809-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: SOUTH BAY RESIDENTIAL HOME	FACILITY NUMBER: 198205247
	VISIT DATE: 03/02/2022

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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff and residents' vaccinations results was conducted. The facility has an approved Mitigation Plan Report on file with CCLD.

Advisory Notes - Technical Assistance was issued, please see LIC9102-AN.

No deficiencies were cited during this inspection visit.

An exit interview was conducted and a copy of this report was provided to Edith Pacleb.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

LIC809 (FAS) - (06/04)

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