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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198205247
Report Date: 03/19/2025
Date Signed: 03/27/2025 08:27:49 AM

Document Has Been Signed on 03/27/2025 08:27 AM - 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/
DIRECTOR:		EDITHA A. PACLEBFACILITY TYPE:
740
ADDRESS:430 WEST 214TH STREETTELEPHONE:
(424) 271-7310
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
03/19/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:Editha PaclabTIME VISIT/
INSPECTION COMPLETED:
04:23 PM
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On March 19, 2025, at 3:30 PM, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced Plan of Corrections visit to the facility following deficiencies noted during the Annual Inspection on February 4, 2025. The LPA met with Editha Paclab, the Administrator, and explained the purpose of the visit.

During the inspection on February 4, 2025, the facility received citations for two issues: 87506 missing or incomplete resident records for residents #1 through #5, and 87608 regarding Postural Supports for Resident #3, who is not on hospice care and had full bed rails in place without a physician's order.

During the visit, the LPA reviewed all resident files and found that all required Community Care Licensing (CCL) forms were adequately maintained and complete. Additionally, the LPA was presented with an authorized physician's order to use full bed rails for Resident #3.

As a result of the audit of resident files, the licensee is now in compliance.

No deficiencies cited during this visit.

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

Janae HammondTELEPHONE: (424) 544-1027
Ernand DabuetTELEPHONE: (323) 629-5526
DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2025
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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