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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320092
Report Date: 08/04/2023
Date Signed: 08/04/2023 03:35:03 PM

Document Has Been Signed on 08/04/2023 03:35 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:LIFESTYLE BOARD AND CAREFACILITY NUMBER:
198320092
ADMINISTRATOR:ANGELES, JENNYLYNFACILITY TYPE:
735
ADDRESS:149 EAST 235TH STREETTELEPHONE:
(562) 743-1037
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 6CENSUS: 4DATE:
08/04/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:59 AM
MET WITH:Jaime Fernandez TIME COMPLETED:
12:00 PM
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On 08/04/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted a case management inspection visit at this facility. LPA met with the caregiver Jaime Fernancez and explained the purpose of the visit is in association with complaint 11-AS-20230726113120. Fernandez contacted administrator Kim Manor who could not be present at this visit.

During inspection visit on 08/02/23, The Department audited client #1 (C1's) Medication Administration Record and was informed (C1) had refused medications and due to the missed medications, (C1) had acted in unacceptable behaviors out in the community and in the group home. The licensee failed to report several incidents involving the health and safety of clients.

The licensee violated Title 22 Regulations 80061 Reporting Requirements. California Code of Regulations (Title 22, Division 6, Chapter 1), deficiency was observed, and citation were issued (ref. LIC 9099-D).

An exit interview is conducted with Jaime Fernandez and a copy of the report is provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2023
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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Document Has Been Signed on 08/04/2023 03:35 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 08/04/2023 at 10:18 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: LIFESTYLE BOARD AND CARE
FACILITY NUMBER: 198320092

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/11/2023
Section Cited
CCR
80061(b)(E)

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80061 Reporting Requirements - (b) Upon the occurrence, during the operation of the facility, of any of the events specified... a report shall be made to the licensing agency within the agency's next working day during its normal business hours... (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.
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The licensee will adhere to Title 22 Section 80061. Plan of correction is for Licensee to submit a LIC 624 Incident Report POC due: 08/11/23 of the incident associated with (C1).
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This requirement was not met as evidenced by: Based on record review and interview, the licensee failed to report the refusal medications for (C1) effects causing unacceptable behaviors. This citation poses a potential health and safety risk to residents in care.

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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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2023


LIC809 (FAS) - (06/04)
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