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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320119
Report Date: 12/05/2024
Date Signed: 12/06/2024 07:49:04 AM

Document Has Been Signed on 12/06/2024 07:49 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:MONTOAK SENIOR LIVING INC.FACILITY NUMBER:
198320119
ADMINISTRATOR/
DIRECTOR:		SHAHEEN, NAJMAFACILITY TYPE:
740
ADDRESS:1700 248TH STREETTELEPHONE:
(310) 406-6193
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY: 12CENSUS: 12DATE:
12/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:22 AM
MET WITH:Najma Shaheen, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On 12/05/2024 at 11:20 AM, Licensing Program Analyst (LPA) Zina Brown conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the one- year inspection. LPA met with Najma Shaheen, Administrator and the purpose of the visit was discussed. Facility is licensed to serve 12 non- ambulatory residents of which four (4) may be bedriddden (room #1 and room #2 approved for bedridden) and approved for hospice waiver for six (6). None of the residents are diagnosed with dementia or receiving home health or hospice care services. The facility does not handle any of the residents’ money. The facility fees are at a balance of $0. Liability Insurance is current with Kinsale Insurance Company (Policy #0100293191-0) effective 04/03/2024-04/03/2025 for $1,000,000 each occurrence /$3,000,000 policy aggregate limit. The last fire drill was conducted on 12/01/2024.

The home is a single story home consisting of: (8) resident bedrooms, (4) full bathroom, a living room, a dining area, a kitchen with two refrigerators, an outside patio area, laundry room outside with an additional refrigerator.

At 11:49 AM LPA toured the resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured a 111.5 F, 107.9 F, and 113.4F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions.

A review of (10) residents service files, (9) staff personnel files and (12 Medication Administration Records (MAR) and did observe discrepancies at the time of visit.

Report continues on LIC 809-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2024
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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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: MONTOAK SENIOR LIVING INC.
FACILITY NUMBER: 198320119
VISIT DATE: 12/05/2024
NARRATIVE
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Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly, and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards.

Deficiencies cited under California Code of Regulations (Title 22, Division 6, Chapter 8); LPA observed the following deficiencies:
On 12/05/2024 at 11:49 am while LPA was conducting a tour of the physical plant, LPA reviewed and observed:
  • padlock on exterior gate
  • 10 out of 12 residents medication was not listed on the MAR, empty and or not check off by staff on consecutive days.
  • LPA conducted a file review of the 6 out of 12 client files and did not observe an Needs and Services Plan within 30 days after admission date.

An exit interview was conducted with Najma Shaheen, Administrator, and a copy of Report and Appeal Rights provided.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/06/2024 07:49 AM - It Cannot Be Edited


Created By: Zina Brown On 12/05/2024 at 03:45 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: MONTOAK SENIOR LIVING INC.
FACILITY NUMBER: 198320119

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above as during medication reviews, LPA observed documentation on the MAR residents missed taking medication for days and or medication was not listed on the MAR which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/26/2024
Plan of Correction
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The administrator will ensure a in-service training for all staff regard medication documentation is completed by POC due date and provide proof of in-service training for all staff via email at zina.brown@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:Zina Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2024


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Document Has Been Signed on 12/06/2024 07:49 AM - It Cannot Be Edited


Created By: Zina Brown On 12/05/2024 at 03:57 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: MONTOAK SENIOR LIVING INC.
FACILITY NUMBER: 198320119

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)(1)
(1) The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462 Social Factors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the facility did not comply with the section cited above for 6 out of 12 clients which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/26/2024
Plan of Correction
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The facility will submit proof of needs and appraisal plan for resident #2, resident #3, resident #7, resident #8, resident# 9, and Resident #11 via email zina.brown@dss.ca.gov by POC due date.
Type B
Section Cited
CCR
87705(I)(1)
(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (1) Licensees shall notify the licensing agency of their intention to lock exterior doors and/or perimeter fence gates.

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. LPAs observed an exterior front gates had padlock in which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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The administrator will adhere to Title 22 Regulation 87705(l)(1) and remove padlocks from front gate exterior or notify licensing agency for an exemption to maintain gate locks. Proof of correction must be sent to zina.brown@dss.ca.gov within 24 hours of POC due date.
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:Zina Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2024


LIC809 (FAS) - (06/04)
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