198320034-8-9-2023-11-AS-RCLD-CUJQ7Q-20230809115532

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320034
Report Date: 08/09/2023
Date Signed: 08/09/2023 11:55:39 AM

Document Has Been Signed on 08/09/2023 11:55 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	CN HOME #5		FACILITY NUMBER:	198320034
ADMINISTRATOR:	MATHARU, PRITAM		FACILITY TYPE:	735
ADDRESS:	2207 ARLINGTON AVE		TELEPHONE:	(310) 612-0978
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90501
CAPACITY: 4		CENSUS: 3	DATE:	08/09/2023
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	09:07 AM
MET WITH:	Mae Maureen Torres		TIME COMPLETED:	12:00 PM

NARRATIVE

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On 08/09/2023, Licensing Program Manager (LPM) Ulysses Cornel and Licensing Program Analyst (LPA) Regina conducted an unannounced Case Management - Annual Continuation visit using the new CARE Inspection Tool. LPM and LPA met with administrator, Mae Maureen Torres and explained the purpose of today’s visit. The facility is licensed to serve four (4) adult clients of between the ages of 18 through 59, up to 4 clients can be Non-ambulatory. There are three (3) Harbor Regional Center clients in placement.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) client rooms, four (4) bathrooms, an office, an activity room, a dining area and kitchen. There is an outside covered area in the front yard with ample seating.

LPA conducted a records review of (3) client records, (4) staff records, (3) clients Personal & Incidental Records and reviewed the facility disaster plan. All client & Staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (3) Client Medication Administration Records and did not observe any discrepancies at the time of visit.

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 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 within Title 22 guidelines. A comfortable temperature was maintained in the facility.

Report continued on LIC809-C

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

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 08/09/2023 11:55 AM - It Cannot Be Edited

Created By: Regina Cloyd On 08/09/2023 at 10:12 AM

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: CN HOME #5	FACILITY NUMBER: 198320034
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85068.4(g)

Acceptance and Retention Limitations. If acceptance or retention of an individual 60 years of age or older would result in the number of persons 60 years of age or older exceeding 50 percent of the census in facilities with a capacity of six or fewer clients... licensee must request an exception in order to accept or retain the individual. The exception request must be made in accordance with Section 80024. The documentation specified in Section 85068.4(c) must be submitted with the exception request. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record reviews, the licensee did not comply with the section cited above in three (3) out of three (3) clients in care were over the age of 60, two (2) out of three (3) clients (C2 and C3) did not have documentation of Age Exceptions granted by the department.This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/24/2023
	Plan of Correction
1 2 3 4	The administrator agreed to submit age exception request for C2 and C3 and will create a plan to ensure that age exception requests are submitted to CCL prior to accepting or retaining clients who are 60 years of age and older. Proof of correction will be submitted to CCD via email regina.cloyd@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:

Regina Cloyd

LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CN HOME #5	FACILITY NUMBER: 198320034
	VISIT DATE: 08/09/2023

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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for residents, staff and visitors, and 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. The facility has an approved Mitigation Plan Report on file with CCLD.

Deficiencies were observed, Title 22 Regulations were cited. On 08/04/203 LPM and LPA observed that of three (3) clients are over 59 years of age. Two (2) out of three (3) clients (C2 and C3) did not have documentation of Age Exceptions granted by the department.

An exit interview was conducted and plans of corrections were developed. A copy of this report and appeals rights were provided with Administrator Mae Maureen Torres.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

LIC809 (FAS) - (06/04)

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