198320082-6-19-2024-11-AS-DESA-D6DVBG-20240619161731

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320082
Report Date: 06/19/2024
Date Signed: 06/19/2024 04:17:40 PM

Document Has Been Signed on 06/19/2024 04:17 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:	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: 6	DATE:	06/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:07 AM
MET WITH:	Paige Esquivel, House Manager		TIME COMPLETED:	04:40 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	On 06/19/2024 at 9:00 am Licensing Program Analyst (LPA) David España conducted an unannounced Required-1-year annual visit. Upon arrival at the facility, LPA España conducted a risk assessment at the front door. Based on the assessment, the facility is clear of COVID-19 infection. LPA verified that the facility has an approved mitigation plan report. LPA was granted access and allowed to enter the facility to conduct the inspection. The facility is licensed for a Residential Care for the Elderly. The capacity is for 6 residents, 6 non-ambulatory, 0 bedridden. Facility has a dementia care plan in place. LPA was greeted and accompanied on inspection by Paige Esquivel, House Manager. LPA toured the physical plant, inspected food service, reviewed staff records, and reviewed resident files for medical status. There are 1 receiving Home Health and 2 receiving Hospice Services. 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. Continued on 809-C

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: A CARING TOUCH BOARD AND CARE II	FACILITY NUMBER: 198320082
	VISIT DATE: 06/19/2024

NARRATIVE

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LPA observed 5 resident bedrooms, 0 bedrooms are for bedridden, and 5 bedrooms are for non-ambulatory. Bedroom 2 has two beds (*shared resident room/there are two residents), two chairs, two nightstands, 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. 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. 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. Facility does not have a washer and dryer on premises. The facility has a landline which was called by LPA and is operational (424-238-8911). 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 locked/stored in under kitchen sink and in shed out back. Water temperature in kitchen and bathrooms measured between 105F and 120F. 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. Seven (7) dual smoke/carbon monoxide detectors are hardwired and interconnected. Continued on 809-C

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: A CARING TOUCH BOARD AND CARE II	FACILITY NUMBER: 198320082
	VISIT DATE: 06/19/2024

NARRATIVE

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They were tested and are fully operational. 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. First aid kit and manual 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. The facility Liability Insurance is current. The facility does not handle cash resources of clients. Records of staff and clients are stored in a locked kitchen cabinet accessible to staff. Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. The facility has activities 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. LPA did not observe any pets or bodies of water at the facility. 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.
The last emergency fire drill was conducted on May 17, 2024. No deficiencies cited during this visit under California Code of Regulations, Title 22, Division 6, Chapter 8.

An exit interview was conducted, and a copy of the report was provided to Paige Esquivel.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

LIC809 (FAS) - (06/04)

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