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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198205247
Report Date: 03/06/2024
Date Signed: 03/06/2024 12:05:12 PM


Document Has Been Signed on 03/06/2024 12:05 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 HOMEFACILITY NUMBER:
198205247
ADMINISTRATOR:EDITHA A. PACLEBFACILITY TYPE:
740
ADDRESS:430 WEST 214TH STREETTELEPHONE:
(424) 271-7310
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY:6CENSUS: 5DATE:
03/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:17 AM
MET WITH:EDITHA A. PACLEBTIME COMPLETED:
12:18 PM
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On 03/06/24, 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 105.0 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 08/20/23 - 08/20/24 policy #001209522.

Evaluation Report Continues on LIC 809-C
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024
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: SOUTH BAY RESIDENTIAL HOME
FACILITY NUMBER: 198205247
VISIT DATE: 03/06/2024
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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. Interviews conducted with (3) residents. The facility is current on CCL annual dues. The facility has a current Administrator Certificate for Editha A Pacleb #6013416740.

Deficiencies:
During record reviews of resident files, LPA identified resident #3 with dementia did not have a current medical assessment or appraisal on file. Staff #1-#4 did not have current First Aid/CPR Training on file when staff files were audited.

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 HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/06/2024 12:05 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: 03/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69.(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above . LPA identified staff #1-#4 did not have a current First Aid/CPR Training. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2024
Plan of Correction
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Licensee/Administrator will ensure that all staff involved with resident's daily care must have a current First Aid/CPR training. Proof of correction must be sent to by POC due date: 03/27/24 to ernand.dabuet@dss.ca.gov
Type B
Section Cited
CCR
87705(c)(5)
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: Cross.
(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. LPA identified resident #3 with dementia last medical assessment was in 2021.This violationwhich poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2024
Plan of Correction
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Licensee/Administrator must adhere to Title 22 87705 and ensure any resident with Dementia must have annual medical assessment and reappraisal. Proof of correction must be sent to by due date 03/27/24 to ernand.dabuet@dss.ca.gov.
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: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024
LIC809 (FAS) - (06/04)
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