198320031-12-1-2022-11-AS-LMOA-CLNRML-20221130120855

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320031
Report Date: 11/30/2022
Date Signed: 12/01/2022 08:09:22 AM

Document Has Been Signed on 12/01/2022 08:09 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	SOUTH BAY MEMORY CARE		FACILITY NUMBER:	198320031
ADMINISTRATOR:	SPIGLANIN, LAUREN		FACILITY TYPE:	740
ADDRESS:	19318 FLAVIAN AVE		TELEPHONE:	(310) 383-1877
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90503
CAPACITY:	6	CENSUS: 6	DATE:	11/30/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	VICTORIA MARTINEZ		TIME COMPLETED:	12:30 PM

NARRATIVE

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On 11/302022, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA called to conduct a risk assessment and spoke with Vatche Khedesian who confirmed the facility is free of Covid-19 infection. LPA met with House Manager Victoria Martinez and explained the purpose of today’s visit.

The facility is licensed for six (6) non-ambulatory residents, with a Dementia Care Program and an approved hospice waiver for two (2) residents. Currently, there is one (1) Hospice resident present during today’s visit.

The facility is a single-story family home located in a residential neighborhood. The facility consisted of the following: Living room, dining area, kitchen, three (3) bedrooms, two (2) bathrooms, laundry area in the garage, indoor/outdoor activity area, shaded patio area, and attached two (2) car garage.

LPA Montoya toured the facility with House Manager Martinez. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client 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 at 119.6 degrees Fahrenheit. 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 sharp objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. There are three (3) fire extinguishers fully charged, one in the kitchen, and two in the hallways to resident bedrooms, smoke detectors and carbon monoxide were operable.

Evaluation Report Continues on LIC 809C

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022

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: SOUTH BAY MEMORY CARE	FACILITY NUMBER: 198320031
	VISIT DATE: 11/30/2022

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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 were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. LPA Montoya requested a copy of the facility's liability insurance emailed to lourdes.montoya@dss.ca.gov.

Technical Advisory was issued.

Deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. LPA observed and took photos of three large blue trash bins and five large gray trash bins stored along the right side yard pathway from the front yard to the backyard of the facility. The facility sketch shows this pathway must be always clear. LPA also observed Staff #1 is not associated to the facility.

Exit interview conducted and appeal rights discussed. A copy of this report and appeal rights provided to House Manager Victoria Martinez.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 12/01/2022 08:09 AM - 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: SOUTH BAY MEMORY CARE	FACILITY NUMBER: 198320031
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(d)(6)

Personal Accommodations and Services

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above. LPA Montoya observed and took photos of eight (8) large trash bins obstructing the passageway of the right side of the facility. The facility sketch shows this pathway must always be clear. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/07/2022
	Plan of Correction
1 2 3 4	Licensee shall ensure the outdoor passageways are always free of obstructions. The house manager agreed and moved the eight trash bins out of the passageway. This deficiency is cleared during today's visit.

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: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 12/01/2022 08:09 AM - 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: SOUTH BAY MEMORY CARE	FACILITY NUMBER: 198320031
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(2)

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 (2) Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above. LPA observed Staff #1 is not associated to the facility. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/01/2022
	Plan of Correction
1 2 3 4	Licensee shall ensure to comply to section cited above. Licencee associated Staff #1 through Guardian during today's visit. This deficiency is corrected today.

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: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022

LIC809 (FAS) - (06/04)

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