198205247-3-20-2023-11-AS-PSCT-CQ4V5T-20230320160827

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198205247
Report Date: 03/20/2023
Date Signed: 03/20/2023 04:08:34 PM

Document Has Been Signed on 03/20/2023 04:08 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:	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: 4	DATE:	03/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:48 PM
MET WITH:	EDITHA A. PACLEB		TIME COMPLETED:	04:00 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 03/20/23, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced annual required visit 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. There are currently four (4) residents in the facility. 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 119.1 F. A comfortable temperature is maintained in the facility. Report continued on LIC809-C

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023

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: SOUTH BAY RESIDENTIAL HOME	FACILITY NUMBER: 198205247
	VISIT DATE: 03/20/2023

NARRATIVE

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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) for four (4) residents they were accurate and maintained in order. A working landline telephone remains available.

LPA conducted a records review of (4) client records and (5) staff records. All client & staff records were complete. The last fire/emergency drill was performed on 1/10/2023. All staff are fingerprint cleared and associated to the facility and have documentation of the required trainings on file.

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: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023

LIC809 (FAS) - (06/04)

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