198320019-2-22-2024-11-AS-RCLD-D2PVYL-20240222155118

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320019
Report Date: 02/22/2024
Date Signed: 02/22/2024 03:51:36 PM

Document Has Been Signed on 02/22/2024 03:51 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, 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:	02/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:54 AM
MET WITH:	Administrator Ethel Culala Monterroso		TIME COMPLETED:	04:05 PM

NARRATIVE

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On 02/22/2024 8:54 AM, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced Required – Annual Inspection and met with Caregiver Renerose Seludo. Administrator Ethel Culala Monterroso joined us 30 minutes later. Six (6) residents and two (2) staff were present during this inspection.

The facility is licensed to operate for six (6) non-ambulatory residents ages 60 and above. Facility is approved for one (1) bedridden (in room one or room three) and has a hospice wavier for four (4) 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 (2) outside covered patio area with a table and chairs. There is an attached garage used for storage with access through the side of the house.

Staff accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards.

Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises.

Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked.

Common areas were clean and clear of hazards, doorways were free of obstructions.

LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxics were kept in locked storage cabinet. First Aid kit was available. One fire extinguisher, last serviced October 11, 2023 was observed in the dining room area. LPA tested all carbon monoxide detectors and smoke detectors located throughout the home. Both devices were functional and interconnected. Continue to LIC 809-C.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024

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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Document Has Been Signed on 02/22/2024 03:51 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: A GRAND HOME CARE	FACILITY NUMBER: 198320019
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(3)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above for one out of five staff members which poses an immediate safety risk to persons in care. Guardian roster search on 02/21/24 did not show S3 associated to the facility and S3 was working on-site during LPA's 02/22/24 facility visit. Per Administrator, S3 started working on 02/09/24.
	POC Due Date: 02/23/2024
	Plan of Correction
1 2 3 4	On 02/22/24 2:25 PM, the Administrator emailed LPA Cloyd S3's criminal record transfer request, criminal record statement, and license. S3 will not return to work until the association is completed. Administrator will refer to PIN 24-04-CCLD to join the Guardian training on 02/28/2024 11:00 AM - 12:00 PM.

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) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: A GRAND HOME CARE	FACILITY NUMBER: 198320019
	VISIT DATE: 02/22/2024

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5 staff records were reviewed, 5 out of 5 staff records had current first aid certificates. Two staff interviews were conducted.

5 resident records were reviewed and, 5 out of 5 client records had Medical Assessments. Two residents’ medication was reviewed. One resident was interviewed.

Deficiencies are being cited based on LPA observation, interviews conducted and record review in accordance with the California Code of Regulations, Title 22, see LIC809D. A violation regarding criminal record clearance warrants an immediate civil penalty of $500.00 and is hereby assessed, see LIC421BG.

The Guardian roster searched on 02/21/24 did not show S3 associated to the facility and S3 was working on-site during LPA's 02/22/24 facility visit. Per Administrator, S3 started working on 02/09/24. On 02/22/24 2:25 PM, the Administrator emailed LPA Cloyd S3's criminal record transfer request, criminal record statement, and license.

An exit interview was conducted, plans of corrections were developed and reviewed, and technical assistance was provided. A copy of this report and appeal rights were discussed and left with the Administrator Ethel Culala Monterroso.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024

LIC809 (FAS) - (06/04)

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