198320082-6-1-2021-11-AS-SCIS-C3KPK4-20210601112232

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320082
Report Date: 06/01/2021
Date Signed: 06/01/2021 11:25:20 AM

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
MONTERY PARK, CA 91754

FACILITY NAME:	A CARING TOUCH BOARD AND CARE II		FACILITY NUMBER:	198320082
ADMINISTRATOR:	WELLS, NICHOLAS		FACILITY TYPE:	740
ADDRESS:	2108 OAK ST		TELEPHONE:	(510) 384-3431
CITY:	SANTA MONICA	STATE: CA	ZIP CODE:	90405
CAPACITY:	6	CENSUS: 0	DATE:	06/01/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:38 AM
MET WITH:	Nicholas Wells		TIME COMPLETED:	11:30 AM

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	On 6/1/2021 Licensing Program Analyst (LPA), Stephanie Cifuentes conducted an announced inspection to the above facility for purpose of a pre-licensing evaluation. An application was submitted to Community Care Licensing Department(CCLD) on 02/22/2021, for an Initial license for a Residential Care for the Elderly. The requested capacity is for 6 clients, 3 non-ambulatory, 3 bedridden. Facility has a dementia care plan in place. LPA was greeted and accompanied on inspection by Nicholas Wells. Facility has 5 client bedrooms, 5 client bathrooms, living room, dining room and kitchen. Facility is a single-story house. The client bedrooms are spacious and will easily accommodate the client's furnishings. There is a shaded side yard with an umbrella, table and chairs. Outdoor passageways, walkways, driveways, steps and patios are free from obstructions. LPA did not observe hazards, such as ladders, gardening tools and/or motorized equipment in the front, back and/or side areas of the facility. Bedrooms Residents: LPA observed 5 resident bedrooms, two bedrooms are for bedridden and three bedrooms are for non-ambulatory. Bedroom 2 has two beds, two chairs, two night stands, overhead lighting, closet and two dressers with several drawers. Bedrooms 1, 3, 4 and 5 have one bed, one chair, one-night stand, overhead lighting, closet or wardrobe and a dresser with several drawers. All drawers comply with the requirement of 8 cubic feet of space and there was ample closet space. Bathroom: Facility has 5 client bathrooms. All bathrooms have working toilets, wash basins and showers/baths. There are grab rails next to both the toilet and the shower as well as nonskid mats in showers. LPA observed adequate lighting in hallway leading to bathrooms via nightlights. Continued on 809-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2021

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

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
MONTERY PARK, CA 91754

FACILITY NAME: A CARING TOUCH BOARD AND CARE II	FACILITY NUMBER: 198320082
	VISIT DATE: 06/01/2021

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

Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcases, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen stored in linen closet, which is at end of the hall between the bedrooms.

Laundry: Facility does not have a washer and dryer on premises. A written plan was submitted to LPA on 6/1/2021 describing how laundry will be handled at the facility.

Emergency Phone Numbers, Exit Plan & Menu: The facility has a landline which was called by LPA and is operational. Emergency Disaster Plan posted & readily available for review on the wall. Two fully charged fire extinguisher were found, one in kitchen and one in hallway.

Toxins: Toxins locked/stored in under kitchen sink and in shed out back.

Water temperature: Water temperature in kitchen and bathrooms measured between 105F and 120F.

Food Service: Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are in magnetically locked drawers. Food supply was adequate and stored in kitchen refrigerator and cabinets and consists of the following: A variety of fresh and canned fruit, vegetable and meat food items.

Smoke Detectors: Seven (7) dual smoke/carbon monoxide detectors are hardwired and interconnected. They were tested and are fully operational.

Appliances: Stove burners and oven are in good working condition. There is 1 refrigerator in the kitchen. Refrigerator and freezer are at the correct temperature for food storage.

Medications, First-Aid Kit & Book: First aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and manual which are stored in locked cabinet, available for staff use but inaccessible to clients.

Continued on 809-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2021

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

FACILITY NAME: A CARING TOUCH BOARD AND CARE II	FACILITY NUMBER: 198320082
	VISIT DATE: 06/01/2021

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

Clients & Staff Files: Applicant will not be handling cash resources of clients. Records of staff and clients shall be stored in a locked kitchen cabinet accessible to staff.

Reading Material, Games, Equipment & Materials: The facility has an activity calendar and provides puzzles, origami, painting, other games and paper crafts as well as a karaoke machine, and chair dancing.
Outside activity area is properly enclosed with self-closing latches and all doors have auditory devices to monitor exits.

Pool/Jacuzzi & Pets: LPA's did not observe any pets or bodies of water at the facility.

Fire clearance: Fire Clearance was approved on 5/12/2021 for 3 bedridden client and 3 non-ambulatory clients with rooms two (2) and three (3) approved for bedridden. LPA did not observe pad locks or other mechanisms which may be obstructions for safe and quick egress during an emergency on side gates and front exits.
Facility has a hospice waiver for 3.

Component III: Conducted at the Pre-Licensing visit, on 6/24/2020 at A Caring Touch Board and Care II, information provided about how to operate the facility within substantial compliance.

An exit interview was conducted, and a copy of this report has been emailed to the applicant. Accordingly, LPA Stephanie Cifuentes will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2021

LIC809 (FAS) - (06/04)

Page: 3 of 3