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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320090
Report Date: 02/22/2023
Date Signed: 02/22/2023 12:06:30 PM

Document Has Been Signed on 02/22/2023 12:06 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:SOUTH BAY FAMILY HOME, LLCFACILITY NUMBER:
198320090
ADMINISTRATOR:CHAVEZ, KARENFACILITY TYPE:
735
ADDRESS:21821 ARCHIBALD AVE.TELEPHONE:
(310) 919-8272
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 4CENSUS: 1DATE:
02/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Kiana Miller - DSPTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mario Leon conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA was met by Kiana Miller, Direct Support Professional (DSP) and the purpose of today’s visit was explained. The facility is licensed to operate and service four (4) ambulatory adults ages 18 through 59, two (2) of which may be non-ambulatory. Currently, one (1) client resides at this facility.

The facility is a one-story structure located in a residential neighborhood. It consists of the following: three (3) bedrooms (one currently used by live-in staff), two (2) client bedrooms, one (1) bathroom, living area, dining area, kitchen, outdoor area with table, chairs and umbrella. Medications were centrally stored, yet were left accessible. All rooms were inspected. Beds and bedding supplies were in good condition. Sufficient lighting was provided. Adequate storage for client personal belongings was observed.

LPA Leon toured the physical plant. There were no bodies of water or obstructions on the premises. 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 112.8 F in the bathroom and 113.3 F in the kitchen.

Storage areas for personal hygiene and sharp objects were stored and not accessible to clients. The cabinet beneath the sink is broken, leaving cleaning supplies and toxins accessible. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly. Two (2) fire extinguishers were fully charged as of 7/29/2022 with receipt . Smoke detectors and carbon monoxide detectors were operable.

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2023
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 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SOUTH BAY FAMILY HOME, LLC
FACILITY NUMBER: 198320090
VISIT DATE: 02/22/2023
NARRATIVE
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During the visit, LPA Leon observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents. Sanitizing stations in common areas and restrooms were available. LPA observed staff was not wearing face covering. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff and resident temperature logs were reviewed. The facility has a Mitigation Plan Report approved by CCLD on file.

During this interview there were three (3) deficiencies cited, see LIC809-D.

During this interview there have been two (2) technical assistance notes provided, see LIC9102.

An exit interview was conducted with Kiana Miller - DSP and a copy of this report, and appeal rights, have been printed and provided to Kiana Miller, DSP.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 02/22/2023 12:06 PM - It Cannot Be Edited


Created By: Mario Leon On 02/22/2023 at 11:07 AM
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: SOUTH BAY FAMILY HOME, LLC
FACILITY NUMBER: 198320090

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above in having the cabinet beneath the sink being in disrepair which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/03/2023
Plan of Correction
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LPA and DSP have agreed that the cabinet below the kitchen sink will be repaired on, or before, the POC due date which is Friday March 3rd, 2023. Administrator, Karen Chavez, will submit media (photo/video) evidence by email to either Mario.Leon@DSS.CA.GOV or Ernand.Dabeut@DSS.CA.GOV.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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:Ulysses Coronel
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2023


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 02/22/2023 12:06 PM - It Cannot Be Edited


Created By: Mario Leon On 02/22/2023 at 11:07 AM
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: SOUTH BAY FAMILY HOME, LLC
FACILITY NUMBER: 198320090

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above in having the side exit screen door in disrepair which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/03/2023
Plan of Correction
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LPA and DSP have agreed that the side exit screen door will be repaired on, or before, the POC due date which is Friday March 3rd, 2023. Administrator, Karen Chavez, will submit media (photo/video) evidence by email to either Mario.Leon@DSS.CA.GOV or Ernand.Dabeut@DSS.CA.GOV.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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:Ulysses Coronel
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2023


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 02/22/2023 12:06 PM - It Cannot Be Edited


Created By: Mario Leon On 02/22/2023 at 11:26 AM
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: SOUTH BAY FAMILY HOME, LLC
FACILITY NUMBER: 198320090

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above in having the medication drawer being left unlocked from 7:00am to 10:00am which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/10/2023
Plan of Correction
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LPA has affirmed that Administrator, Karen Chavez, will conduct staff training on proper medication storage on, or prior to, the POC due date which is March 10th, 2023. The following will be submitted, via email to Mario.Leon@DSS.CA.GOV or Ernand.Dabeut@DSS.CA.GOV; essay style report of the sections of Title 22 regulation that had been covered, the length of the training, and the names/signatures of those who had attended.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Ulysses Coronel
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2023


LIC809 (FAS) - (06/04)
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