198320119-1-28-2023-11-AS-EDAT-CNHUHP-20230128143615

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320119
Report Date: 01/28/2023
Date Signed: 01/28/2023 02:37:01 PM

Document Has Been Signed on 01/28/2023 02:37 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:	MONTOAK SENIOR LIVING INC.		FACILITY NUMBER:	198320119
ADMINISTRATOR:	SHAHEEN, NAJMA		FACILITY TYPE:	740
ADDRESS:	1700 248TH STREET		TELEPHONE:	(310) 406-6193
CITY:	LOMITA	STATE: CA	ZIP CODE:	90717
CAPACITY:	12	CENSUS:	DATE:	01/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:56 AM
MET WITH:	Dr. Khalid Anwar		TIME COMPLETED:	01:16 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 01/28/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA met with administrator Najma Shaheen and explained the purpose of today’s visit. The facility is licensed to operate for twelve (12) elderly non-ambulatory adults of which four (4) may be bedridden. The facility is approved for six (6) hospice residents. Currently, seven (7) resident are DHS and (2) are private pay. The facility is a single-story structure located in a residential neighborhood. It consists of the following: (8) resident's rooms, (4) common bathrooms, a living area, a dining area, a kitchen, and an outside patio area. LPA and administrator toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. 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 hot water temperature was tested at 108.1 F. A comfortable temperature of 71 degrees was maintained in the facility. LPA observed the facility to be appropriately furnished at the time of visit. Storage areas for personal hygiene, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. The facility has several fire extinguishers that were charged, smoke detectors, and carbon monoxide was operable. A working landline telephone remains available. The facility has a current liability insurance effective 0801/2022 – 08/01/2023. Evaluation Report Continues on LIC 809-C

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2023

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 01/28/2023 02:37 PM - It Cannot Be Edited

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: MONTOAK SENIOR LIVING INC.	FACILITY NUMBER: 198320119
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. 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 missing handle for kitchen cabinet andd ceiling plaster peeling in room #6. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/28/2023
	Plan of Correction
1 2 3 4	Licensee will ensure is to repair the ceiling in room #6 and replace a missing cabinet kitchen handle. Proof of correction sent by fax 323-981.1781 to El Segundo Regional office by 02/28/23.

Type B

Section Cited

CCR

87412(a)(11)

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: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on (observation and record review), the licensee did not comply with the section cited above. LPA identify staff #3 did not have health screenign for (TB). This violaiton which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/11/2023
	Plan of Correction
1 2 3 4	Licensee will ensure to adhere to Title 22 87412 and obtain Health Screeng and TB for staff #3. Proof of correction sent by fax 323-981.1781 to El Segundo Regional office by 02/11/23.

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	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/28/2023 02:37 PM - It Cannot Be Edited

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: MONTOAK SENIOR LIVING INC.	FACILITY NUMBER: 198320119
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on (observation) (record review), the licensee did not comply with the section cited. LPA identified staff #2,#3,#4, #5 and staff #7 did not have current CPR First Aid. This violation poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/11/2023
	Plan of Correction
1 2 3 4	Licensee will ensure to adhere to Title 22 87411 and obtain CPR/First Aid for all staff including the staff #2-#5 and #7. Proof of correction sent by fax 323-981.1781 to El Segundo Regional office by 02/11/23

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: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2023

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: MONTOAK SENIOR LIVING INC.	FACILITY NUMBER: 198320119
	VISIT DATE: 01/28/2023

NARRATIVE

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INFECTION CONTROL:
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 staff wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of the resident's and staff's vaccination records was conducted. The facility has a Mitigation Plan Report on file with CCLD and an Infection Control Plan.

DEFICIENCY:
Based on record reviews, LPA identified the following staff #2, #, #4, #5 and #7 all did not have active CPR/First Aid or CPR/First Aid Certificate on file. LPA identified staff #3 did not have a health screening LIC 503 and a TB test. LPA observed the lower kitchen drawer missing a cabinet handle and room #6 had peeling ceiling plaster.

Based on interviews, observation, and record reviews the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8,

Deficiency are issued and an exit interview is conducted with Najma Shaheen. A copy of this report, appeal rights, and civil penalty were provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2023

LIC809 (FAS) - (06/04)

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