198205247-2-4-2025-11-AS-EDAT-DDL5L9-20250204190246

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198205247
Report Date: 02/04/2025
Date Signed: 02/04/2025 07:03:48 PM

Document Has Been Signed on 02/04/2025 07:03 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:	SOUTH BAY RESIDENTIAL HOME		FACILITY NUMBER:	198205247
ADMINISTRATOR/ DIRECTOR:	EDITHA A. PACLEB		FACILITY TYPE:	740
ADDRESS:	430 WEST 214TH STREET		TELEPHONE:	(424) 271-7310
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	02/04/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:07 AM
MET WITH:	EDITHA A. PACLEB		TIME VISIT/ INSPECTION COMPLETED:	02:39 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 02/04/25, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with administrator Editha Pacleb . LPA explained the purpose of today’s visit. The facility is licensed to operate for six (6) non-ambulatory elderly adults ages 60 and above. The facility is approved for one (1) hospice waiver. Currently, there is one hospice resident. The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) residents' rooms, one (1) staff room, two (2) bathrooms, a living area, a dining area, a kitchen, and an outside patio area. LPA 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, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of the visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. A water temperature of 105.7 degrees F. A comfortable temperature was maintained in the facility. LPA observed the facility to be sanitary and appropriately furnished during the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained adequately. The fire extinguishers were charged, and smoke detectors and carbon monoxide were operable. A review of Medication Records Administration (MAR) was observed to be maintained in order and accurate. The facility has a current liability insurance effective 08/20/24 - 08/20/25 policy #001209523. Evaluation Report Continues on LIC 809-C

Janae Hammond	TELEPHONE: (424) 544-1027
Ernand Dabuet	TELEPHONE: (323) 629-5526
	DATE: 02/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025

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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Document Has Been Signed on 02/04/2025 07:03 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: SOUTH BAY RESIDENTIAL HOME	FACILITY NUMBER: 198205247
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87506(a)

87506(a) Resident Records. A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. LPA identified Residents #1-#5 all had missing or incomplete required CCL forms (See LIC858). This violaton which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/21/2025
	Plan of Correction
1 2 3 4	The administrator, shall review the file for R1, ensuring the required documents are filled out and signed in the file. The administrator shall also send a written statement to CCL to the attention of LPA Dabuet that all resident files are complete, and she will ensure that all records/files are complete at times. Proof of correction is due by 02/21/25.

Type B

Section Cited

CCR

87608(3)

87608 Postural Supports (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA identified Resident #3 who is not on hospice with full bedrails without physicians order. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/21/2025
	Plan of Correction
1 2 3 4	The administrator, shall review Title 22 Regulation 87608. The administrator shall obtain a written prescription for full bedrails. The administrator shall also send a written statement to CCL to the attention of LPA Dabuet that regulations have been reviewed and a physicians order for full bed rails is obtained. Proof of correction is due by 02/21/25.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Janae Hammond	TELEPHONE: (424) 544-1027
Ernand Dabuet	TELEPHONE: (323) 629-5526
	DATE: 02/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025

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: SOUTH BAY RESIDENTIAL HOME	FACILITY NUMBER: 198205247
	VISIT DATE: 02/04/2025

NARRATIVE

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During the visit, LPA observed the facility's infection control practices. LPA observed staff followed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). Posters mandated for inspection control were posted.

An audit of residents #1-#5 (R1-R5) service records and staff #1-#4 (S1-S4) personnel records. The facility is current on CCL annual dues. The facility has a current Administrator Certificate for Editha A Pacleb 7003753740 valid through 01/31/2024 01/31/2026.

Deficiencies:
During record reviews of resident files, LPA identified all Resident #1-#5 files were incomplete or mssing. Required CCL forms filled out and no acknowledgement signatures from residents. LPA identified Resident #3 not on hospice care had full bed rails with no physician's order.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 9099-D).

An exit interview conducted with Editha Paclab and a copy of the report is provided.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 02/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025

LIC809 (FAS) - (06/04)

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