198320019-2-17-2023-11-AS-ARID-CP5VTA-20230217154249

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320019
Report Date: 02/17/2023
Date Signed: 02/17/2023 03:43:04 PM

Document Has Been Signed on 02/17/2023 03:43 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:	A GRAND HOME CARE		FACILITY NUMBER:	198320019
ADMINISTRATOR:	CULALA, ETHEL		FACILITY TYPE:	740
ADDRESS:	1132 LEVINSON ST		TELEPHONE:	(310) 212-7429
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90502
CAPACITY: 6		CENSUS: 6	DATE:	02/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:38 PM
MET WITH:	Ethel Culala		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 02/17/2023, Licensing Program Manager (LPM) Ulysses Coronel and Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with administrator Ethel Culala and explained the purpose of today’s visit. The facility is licensed to operate for six (6) elderly non-ambulatory residents ages 60 and above. Facility is approved for one (1) bedridden and has a hospice wavier for two (2) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident's rooms, a staff room, two (2) bathrooms, living area, dining area, office area, kitchen, laundry area between the kitchen and hallway and outside covered patio area with a table and chairs. There is an attached garage used for storage with access through the front of the garage and side of the house. LPA and administrator 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 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 between 105.3 F and 108.5 F in the bathroom and kitchen. A comfortable temperature was maintained in the facility. 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. One (1) fire extinguisher was fully charged in the dining area, smoke detectors and carbon monoxide were operable. A review of Medication Administration Records (MAR) was maintained in order and accurate. First aid kit available near the laundry area. Evaluation Report Continues on LIC 809-C

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023

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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Document Has Been Signed on 02/17/2023 03:43 PM - It Cannot Be Edited

Created By: Antonine Richard On 02/17/2023 at 03:07 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: A GRAND HOME CARE	FACILITY NUMBER: 198320019
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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 Observed a hand shovel outside by the canopy accessible, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/21/2023
	Plan of Correction
1 2 3 4	The Adminsitrator stored the hand shovel during today visit, and will create aplan to ensure future complacience. Proof of correction will be sumitted vial email. 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

LICENSING EVALUATOR NAME:

Antonine Richard

LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023

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: A GRAND HOME CARE	FACILITY NUMBER: 198320019
	VISIT DATE: 02/17/2023

NARRATIVE

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During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff and residents were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE) except for N95 and Disposable Gowns. All mandated inspection control posters were posted.

Deficiency and Advisory Notes - Technical Assistance were issued, please see LIC809D and LIC9102-AN..

An exit interview was conducted and plans of corrections developed. A copy of this report and appeals rights were provided to Ethel Culala.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023

LIC809 (FAS) - (06/04)

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