198320044-10-9-2023-11-AS-WGIS-CWG2V9-20231009174335

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320044
Report Date: 10/09/2023
Date Signed: 10/09/2023 05:43:42 PM

Document Has Been Signed on 10/09/2023 05:43 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

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: 4	DATE:	10/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Minda MacNamara		TIME COMPLETED:	04:45 PM

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On 10/09/23, Licensing Program Analyst (LPA), Wendy Gibbs, conducted and unannounced annual visit using the full Cares Tool. LPA met with Administrator, Minda Mcnamara, and explained the purpose of today’s visit. The facility is licensed to serve six (6) non-ambulatory elderly residents ages 60 and above of which two (2) can be bedridden and four (4) can be on hospice care. There were four (4) Residents present during the time of visit.
Structure/Physical Plant The facility is a single-story home in a residential neighborhood. The home has five (5) bedrooms, 3 bathrooms, kitchen, dining room, living room, attached garage, and outside shaded patio area. LPA toured the facility inside and outside with Administrator. All walkways were observed to be clean, clear, and free of obstruction, hazards, and debris. LPA did not observe any bodies of water on the premises.

Bedroom LPA inspected all Resident bedrooms. LPA observed all rooms to have the required furniture including a bed, dresser, nightstand with lamp, chair, and storage space for residents’ personal belongings. All beds had the required linens including a mattress cover, fitted sheet, blankets, comforter, and pillows. LPA observed the bedrooms to be clean and in good repair. LPA observed an additional supply of linens stored in residents’ closets and in a cabinet in the hallway.

Bathrooms LPA inspected all resident bathrooms and found them to be within Tittle 22 regulations. All fixtures were working properly. There are secured safety handrails, a nonskid mat, and a shower chair. LPA observed an ample supply of hygiene products stored in cabinets. The water temperature in the bathrooms measured 117.3-degrees and 114.2-degrees Fahrenheit.

Kitchen LPA inspected the kitchen and observed it to be clean and sanitary. All appliances were in good working repair. LPA observed an ample supply of cutleries, pots, and pans to be in good repair. LPA observed a 3-day supply of perishable foods and a 7-day supply of non-perishable foods. All sharps are secured in a locked drawer in the kitchen. All cleaning supplies are secured in the locked cabinet in the kitchen and are inaccessible to residents. The water temperature measured 110.3-degress Fahrenheit.

Continued on LIC9099-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023

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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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: ALTERNATIVE RESIDENTIAL CARE	FACILITY NUMBER: 198320044
	VISIT DATE: 10/09/2023

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Common Rooms LPA inspected all common rooms. The dining room has a large rectangular table and six (6) chairs to accommodate all residents. The living room has a large couch and four (4) recliners to accommodate all residents. All walkways and hallways inside were observed clean, clear, and free of obstructions and hazards. All common rooms and walkways have ample lighting. LPA observed games and activities. The facility was maintained at a comfortable temperature of 74 degrees Fahrenheit.

Medication All Centrally Stored Medications are stored in a locked cabinet in the dining room and are inaccessible to Resident’s. LPA reviewed the medications for two (2) Residents and the MARs and found them to be consistent with properly documented records.

File Review/Interviews LPA reviewed three (3) Resident files and found it contained the required documentation. LPA interviewed two (2) Residents, and all were happy with the care they receive at the facility. LPA reviewed four (4) Staff files and found they contained the required certification and training. LPA interviewed the Administrator, and three (3) staff, all staff were able to answer questions regarding policy, care, personal rights, and procedure.

Safety LPA observed a fully charged fire extinguisher last serviced on 04/13/23 mounted in the dining room. The sprinkler system and smoke and carbon monoxide detector were last serviced and inspected on 04/12/23. The last emergency drill was conducted on 09/15/23. All exits are marked and a facility sketch with the exit route is posted in all Resident rooms and in the dining room. LPA observed all required documents posted throughout the facility. The facility has a working landline telephone. LPA inspected the First Aid Kit and found it contained all the required items and a manual.

Infection Control 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 the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated infection control posters were posted.

No deficiencies were observed or cited during today's visit.

An exit interview was conducted with Administrator Minda Mcnamara, and a copy of this report was provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023

LIC809 (FAS) - (06/04)

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