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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320092
Report Date: 01/13/2024
Date Signed: 01/13/2024 04:03:56 PM

Document Has Been Signed on 01/13/2024 04:03 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:LIFESTYLE BOARD AND CAREFACILITY NUMBER:
198320092
ADMINISTRATOR:MANOR, KIMFACILITY TYPE:
735
ADDRESS:149 EAST 235TH STREETTELEPHONE:
(562) 743-1037
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 6CENSUS: 6DATE:
01/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH:KIM MANORTIME COMPLETED:
12:35 PM
NARRATIVE
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On 01/13/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with the administrator Kim Manor. LPA explained the purpose of today’s visit. The facility is licensed to operate for four (6) developmentally disable adults ages 18-59.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: three (3) shared clients' rooms, two (2) bathrooms, (1) staff room, a living area, a dining area, a kitchen, and an outside patio area.

LPA toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of the visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 107.6 F. A comfortable temperature of 70 degrees was maintained in the facility.

LPA observed the facility to be sanitary and appropriately furnished during the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained adequately. A fire extinguisher was charged, and smoke detectors and carbon monoxide were operable. A review of Medication Records Administration (MAR) and Fire Drills were observed to be maintained in order and accurately. The facility conducted Fire/Safety Drill on 01/04/24. The facility has a working landline.

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2024
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 4
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: LIFESTYLE BOARD AND CARE
FACILITY NUMBER: 198320092
VISIT DATE: 01/13/2024
NARRATIVE
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

An audit review of client #1-#6 (C1-C6) files and staff #1-#4 (S1-S4) personnel files. The facility is current on CCL license annual fees.

Deficiency:
During client's audit of staff records, staff #3 was missing health screening, TB results, and training records. Staff #4 personnel file was not available for review. Bathroom #1 sink is clogged and not draining properly the bathtub hot water faucet is loose.

An exit interview was conducted and a copy of this report was provided to administrator Kim Manor.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 01/13/2024 04:03 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 01/13/2024 at 11:50 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: LIFESTYLE BOARD AND CARE
FACILITY NUMBER: 198320092

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA identified a bathroom #1 sink is not draining and bathtub faucet is loose. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/20/2024
Plan of Correction
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LIcensee will ensure the facilty is in working condition at all times. Licensee will have the bathroom sink and bathtub faucet repaired. Proof of correction must be sent to LPA by due date: 01/20/24 - Email: ernand.dabuet@dss.ca.gov
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. LPA identified staff #3 was missing TB test results and Health Screening LIC 503 and no training records on file. This violiation poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/20/2024
Plan of Correction
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Licensee will ensure that all staff files are completed. Licensee will provide proof of TB test result, Health Screening LIC 503 and required training for staff #3. Proof of correction must be sent to LPA by 01/20/24. - Email: ernand.dabuet@dss.ca.gov
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: 01/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/13/2024 04:03 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 01/13/2024 at 12:04 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: LIFESTYLE BOARD AND CARE
FACILITY NUMBER: 198320092

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(c)
80066 Personnel Records (c) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. removal of records shall be subject to the following requirements:


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. LPA identified staff #4 records was not available at the facility during the inspection for review. Ths violaiton poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/20/2024
Plan of Correction
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Licensee will ensure all that all staff records are available for CCL to audit and review as requested. LIcensee will send proof of correction to LPA by due date: 01/20/24 - Email: ernand.dabuet@dss.ca.gov
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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2024


LIC809 (FAS) - (06/04)
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