198205318-5-24-2023-11-AS-ARID-CS5V9C-20230524161406

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198205318
Report Date: 05/24/2023
Date Signed: 05/24/2023 04:14:29 PM

Document Has Been Signed on 05/24/2023 04:14 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:	AMERICARE ASSISTED LIVING OF WALTERIA		FACILITY NUMBER:	198205318
ADMINISTRATOR:	MARLOWE ANTHONY JOAQUIN		FACILITY TYPE:	740
ADDRESS:	2638 PACIFIC COAST HIGHWAY		TELEPHONE:	(310) 326-1838
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90505
CAPACITY:	6	CENSUS: 5	DATE:	05/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:13 AM
MET WITH:	LEIA JOAQUIN		TIME COMPLETED:	04:30 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	Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced Annual required and infection control visit to the above facility. LPA was met by Whilma Torres, care staff and later met with Leia Joaquin, administrator and the purpose of today’s visit was explained. There are currently (5) residents in the facility. (5) residents are ambulatory and (0) are non-ambulatory. The facility is a single-story structure located in a residential neighborhood. It consists (6) bedrooms, (3) full bathrooms, and 1/2 bath, shaded back yard, front yard, laundry room and a detached 2 garage. LPA Antonine Richard and Whilma Torres toured the entire facility inside and out. Documents are posted as mandated. Bedrooms 1-5 are occupied by residents and contain the mandated furniture. The bathrooms are clean and operational. First aid kit is fully stocked with manual, smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to residents. Ample supply of perishable and nonperishable food. The hot water temperature tested 135.8F to 133.3F degrees Fahrenheit. Linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents, 2 fire extinguishers were fully charged, fire drill conducted on 04/24/2023. First Aid kit complete with Manual. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in good repair. During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station. The resident’s temperatures are checked and logged once a day. PPE's are enough for 30 days. At the facility entry, visitors are logged, and temperature checked, sanitizer/soap in the staff bathroom and additional sanitation supplies are locked in the garage. LPA observed staff and residents wearing masks, resident private rooms will be converted to isolation rooms (if needed) and required postings throughout the facility. LPA received a copy of the facility Liability Insurance.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Antonine Richard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

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: AMERICARE ASSISTED LIVING OF WALTERIA	FACILITY NUMBER: 198205318
	VISIT DATE: 05/24/2023

NARRATIVE

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According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did observe deficiencies, Hot water temperature in bathroom #1 tested 135.8F and bathroom #2 at 133.3F degrees.

Therefore citations were issued at the time of visit.

An exit interview is conducted with staff Whilma Torres, a copy of report provided along with appeal rights.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Antonine Richard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 05/24/2023 04:14 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: AMERICARE ASSISTED LIVING OF WALTERIA	FACILITY NUMBER: 198205318
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). 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 in the hot water temperature tested at 135.8F and 133.3F) which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/25/2023
	Plan of Correction
1 2 3 4	The staff adjusted the water temperature between 105.3F and 110.4F degrees. the administrator will create aplan to ensure future compliance. The Administrator will submit proof of correction via email to Antonine.Richard@dss.ca.gov

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Antonine Richard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

LIC809 (FAS) - (06/04)

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