<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320092
Report Date: 10/14/2022
Date Signed: 11/08/2022 10:55:10 AM

Document Has Been Signed on 11/08/2022 10:55 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
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: DATE:
10/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Kim ManorTIME COMPLETED:
04:30 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 10/14/2022 Licensing Program Analyst (LPA), Wendy Gibbs and Ernand Dabuet conducted an unannounced annual required visit using CARE inspection tool. LPA’s met with Mary Manor and explained the purpose of today’s visit. The facility is an Adult Residential Facility to serve Mentally Disabled Adults for ages 18 to 59 years The facility is licensed to operate for six (6) ambulatory.

Structure: Facility is a single-story structure located in a residential neighborhood and consists of: three (3) client bedroom, one (1) staff room, one (1) and a half bathroom.

Physical Plant There is a back yard with a shaded patio area and chairs. Shaded area has sufficient tables and chairs for clients. 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: Bedrooms 1, 2 and 3 have two beds, two chairs, two dressers, two night stands or a shared night stand, over-head lighting and shared closets. The closet and drawers comply with the requirement of 8 cubic feet of space. The client bedrooms are spacious and easily accommodate the client's furnishings.

Staff room: Facility has a staff room that currently has a bed and extra supplies.

Bathrooms: Facility has one and a half bathrooms. Bathroom 2 was observed to have a working toilet, wash basin and showers/bathtubs. Bathroom 1, the half bath, has a working toilet and sink. Water temperature measuring 128.8 degrees F.

Being amended for clarification for line #3 from Developmentally to Mentally.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2022
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 5
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: LIFESTYLE BOARD AND CARE
FACILITY NUMBER: 198320092
VISIT DATE: 10/14/2022
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, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen; sheets, pillow cases, hand towels, bath towels and wash cloths where observed stored in the hallway cupboard. Facility provides hygiene supplies to clients and LPA observed an adequate supply of tooth paste, shampoo, conditioner, body wash and deodorant.

Emergency Phone Numbers, Exit Plan & Menu: The telephone, which is a land line, was checked by LPA and is operational. Emergency Disaster Plan and "See something, Say something, Let Us Know" posted & readily available for review on the wall between of the living room. A fully charged fire extinguisher was found next to the kitchen and in the hallway by bathroom. Last fire drill was on 06/24/2022.

Kitchen: Dishes, cups and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in a locked closet in dining room. Food supply was adequately stored in kitchen refrigerator and cabinets and consists of the following: a variety of fresh and canned fruit, vegetables and meats. All stove burners and oven in working order.

Smoke Detectors: Six dual smoke and carbon monoxide detectors are hardwired and interconnected. All were operational.

Appliances: Stove burners, oven, microwave, dish washer, washer, and dryer working. There is 1 refrigerator in the kitchen and a second refrigerator in the staff room. Refrigerator and freezer are at the correct temperature for food storage. Toxins: Locked/stored in cabinet located in hallway.

Medications, First-Aid Kit & Book: Area for medication storage is in a closet in dining area. First aid kit was inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze. First aid and medications are available for staff use but inaccessible to clients. There was also a First Aid manual.

Clients & Staff Files: Records of staff and clients are stored in cabinets in staff room. LPA's reviewed MAR's.



Reading Material, Games, Equipment & Materials: The facility has board games, books, and other recreational materials for the client's use as well as an activity calendar.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 10/18/2022 01:20 PM - It Cannot Be Edited


Created By: Wendy Gibbs On 10/14/2022 at 03:09 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: LIFESTYLE BOARD AND CARE
FACILITY NUMBER: 198320092

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. LPA identified in bathroom 1 temperature at 129.8 F. This violation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2022
Plan of Correction
1
2
3
4
The licensee wil adher to title 22 80088(e)(1). The licensee will perform knowledge of and conform to applicable laws, rule and regulations. The licensee will comply to water temperature 105-120 F. POC must be sent to LPA by 10/17/2022.
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:Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2022


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 10/18/2022 01:20 PM - It Cannot Be Edited


Created By: Wendy Gibbs On 10/14/2022 at 03:25 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: LIFESTYLE BOARD AND CARE
FACILITY NUMBER: 198320092

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(1)

80069 Client Medical Assessment
(1) A physical examination of the person, indicating the physician's primary diagnosis and secondary diagnosis, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record revie, the licensee did not comply with the section cited above. LPA observed R3's folder is missing a Physician Report LIC 602. This violation which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2022
Plan of Correction
1
2
3
4
The licensee wil adher to title 22 80069(1). The licensee will perform knowledge of and conform to applicable laws, rule and regulations. The licensee will obtain a Physican's Report for R3 by POC 10/28/2022.
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:Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2022


LIC809 (FAS) - (06/04)
Page: 4 of 5
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: LIFESTYLE BOARD AND CARE
FACILITY NUMBER: 198320092
VISIT DATE: 10/14/2022
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
Infection Control
During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, 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. LPA's reviewed all staff and clients vaccination cards.

Deficiencies
LPA observed at 3pm water temperature was tested in bathroom 1 at 129.8 F. During record review LPA identified C3 was missing a physician's report on file.

Deficiencies are issued and exit interview conducted with Administrator Kim Manor. A copy of the report is provided and appeal rights.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5