198320044-9-19-2024-11-AS-SDAY-D99TL7-20240919144904

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320044
Report Date: 09/19/2024
Date Signed: 09/19/2024 02:49:10 PM

Document Has Been Signed on 09/19/2024 02:49 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	ALTERNATIVE RESIDENTIAL CARE		FACILITY NUMBER:	198320044
ADMINISTRATOR:	MCNAMARA, MINDY		FACILITY TYPE:	740
ADDRESS:	2653 W 225TH STREET		TELEPHONE:	(310) 325-1735
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90505
CAPACITY:	6	CENSUS: 5	DATE:	09/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:42 AM
MET WITH:	Huelar Eusebio, caregiver		TIME COMPLETED:	03:00 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

Licensing Program Analyst (LPA) Sparkle Day conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the one-year inspection. LPA met with Huelar Eusebio, caregiver and the purpose of the visit was discussed. The facility is licensed to serve 6 non- ambulatory residents of which 2 residents may be bedridden. Rooms #1, #2, #4 and #5 are bedridden approved. The facility has approved hospice waiver for 4 residents. There is currently (1) resident receiving hospice services. The facility does not handle any of the residents’ money.

This home is a single story home consisting of: (5) resident bedrooms, (3) bathroom, living room, kitchen with dining area, laundry room (located in the attached garage) and an outdoor shaded patio area. LPA toured the Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. 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, water temperature measured between 118.1F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions.

Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

According to California Code of Regulations (Title 22, Division 6, Chapter 8) LPA observed the following

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Sparkle Day	TELEPHONE: (424) 544-1075
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

Document Has Been Signed on 09/19/2024 02:49 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: ALTERNATIVE RESIDENTIAL CARE	FACILITY NUMBER: 198320044
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411c1

All RCFE staff who assist residents with personal activities and/or daily living shall receive appropriate training in first aid from persons qualified by such agencies as the American Cross This requirement is not met as evidenced by: Two (2) staff did not have current First Aid certificate on file at time of visit.
	Deficient Practice Statement
1 2 3 4	Based on The observation of the LPA], the licensee did not comply with the section cited above in [2] out of [4] (persons)] which poses/posed a potential health, safety or personal rights risk to persons in care. Two staff did not have current First Aid certificates on file at time of visit ( Staff #1 Huelar Eusebi and Staff #2 Marietta Polbondo)
	POC Due Date: 09/26/2024
	Plan of Correction
1 2 3 4	Administrator agrees that all staff will have current first Aid certificates by POC date. 9/26/24 Administrator will send proof to Sparkle.day@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: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Sparkle Day	TELEPHONE: (424) 544-1075
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: ALTERNATIVE RESIDENTIAL CARE	FACILITY NUMBER: 198320044
	VISIT DATE: 09/19/2024

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
26
27
28
29
30
31
32

deficiency and issued a citation.

Staff #1 and Staff #2 did not have current First Aide certificates at time of visit.

An Exit interview was conducted with Huelar Eusebio, caregiver. The Appeal rights and a copy of this report was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Sparkle Day	TELEPHONE: (424) 544-1075
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3