198320063-8-5-2022-11-AS-LMOA-CGZM3C-20220805091455

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320063
Report Date: 08/02/2022
Date Signed: 08/05/2022 09:15:02 AM

Document Has Been Signed on 08/05/2022 09:15 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	AMOR VIDA CARE		FACILITY NUMBER:	198320063
ADMINISTRATOR:	MCNAMARA, MINDY		FACILITY TYPE:	740
ADDRESS:	2049 W 235TH STREET		TELEPHONE:	(310) 530-7104
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90501
CAPACITY: 6		CENSUS: 6	DATE:	08/02/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Minda McNamara/Barbara Papilla		TIME COMPLETED:	01:45 PM

NARRATIVE

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On 8/2/2022, 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. Upon arrival at the facility, LPA Montoya called the facility, spoke with House Manager (HM) Barbara Papilla and conducted a risk assessment. Based on the assessment, the facility is clear of Covid-19 infection. The designee, Minda Mcnamara, arrived later and joined the visit.

The facility is licensed for six (6) non-ambulatory residents, of which one (1) may be bedridden and an approved hospice waiver for three (3) residents. Currently, the facility has six (6) residents of which three (3) are hospice residents.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) resident bedrooms, living area, dining area, kitchen, and outside covered patio area.

LPA Montoya toured the inside and outside grounds of the facility with HM Papilla. 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 was provided, storage for resident 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 116.2 degree F. A comfortable temperature of 79 degree F. 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 sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. The facility has (2) fire extinguishers that were charged, smoke detectors, and carbon monoxide were operable. The facility conducted a Fire/Safety Drill on 6/10/2022. A working telephone (310)530-7104 remains available.

Evaluation Report Continues on LIC 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: AMOR VIDA CARE	FACILITY NUMBER: 198320063
	VISIT DATE: 08/02/2022

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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, residents and staff, 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.

Advisory Notes - Technical Assistance were issued, please see LIC9102-AN.

California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

An exit interview was conducted, and a copy of this report and appeal rights were provided to Designee Minda McNamara.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/05/2022 09:15 AM - It Cannot Be Edited

Created By: Lourdes Montoya On 08/02/2022 at 12:49 PM

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: AMOR VIDA CARE	FACILITY NUMBER: 198320063
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(j)

Care of Persons with Dementia

(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above. LPA Montoya observed the auditory devices in the main door, sliding door, resident bedrooms #2, and #4 are not operable. This presents hazard to residents with dementia. Out of six (6) residents, five (5) residents have dementia. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/12/2022
	Plan of Correction
1 2 3 4	The licensee shall ensure all auditory devices are operable. The licensee shall submit a POC to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date, 8/12/2022.

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:

Eva M Alvarez

LICENSING EVALUATOR NAME:

Lourdes Montoya

LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

LIC809 (FAS) - (06/04)

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