198320131-9-26-2022-11-AS-EDAT-CJMUZ9-20220926160110

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320131
Report Date: 09/26/2022
Date Signed: 09/26/2022 04:01:32 PM

Document Has Been Signed on 09/26/2022 04:01 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:	SEASONS MEMORY CARE AT ROLLING HILLS		FACILITY NUMBER:	198320131
ADMINISTRATOR:	THORNTON, TIERRE		FACILITY TYPE:	740
ADDRESS:	2455 PACIFIC COAST HWY		TELEPHONE:	(424) 488-0593
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90505
CAPACITY:	68	CENSUS: 27	DATE:	09/26/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:48 PM
MET WITH:	Tierre Thorton		TIME COMPLETED:	03:59 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	Ernand Dabuet, Licensing Program Analyst (LPA), conducted an unannounced annual required visit on 09/26/22, with a primary focus on Infection Control measures. The LPA met with Tierre Thornton, the administrator. LPA explained the purpose of today’s visit. The facility is licensed to serve (68) of which (60) are non-ambulatory and (68) bedridden elderly adults ages 60 and above. The facility is approved for (10) hospice residents. Currently, the facility has (2) residents on hospice care. The facility is a two-story structure located in a commercial neighborhood. It consists of the following: (47) resident bedrooms. Each room has a bathroom in the unit. There are administrative offices, a copy room, an activity area, a dining area, a kitchen, a beauty shop, medication rooms, and an outside patio. LPA toured the physical plant with Thornton. 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. Bathrooms were found to be within Title 22 regulations and were operational. LPA observed temperatures ranging from 67 degrees F to 76 degrees F. The water temperature was consistent throughout the facility at 119.4 degrees F. During the visit, LPA found the facility to be clean and well-furnished. Storage areas for personal hygiene, cleaning supplies, toxins, 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. All fire extinguishers were fully charged, and smoke detectors and carbon monoxide were operable. A review of Fire Drills was observed to be maintained in order and accurate. The last fire drill was performed on 09/07/22 at 1:30 pm. Several working landline phones are available on-site. A review of Electronic Medication Administration Record is maintained in order. The facility maintains a Certificate of Liability Insurance in current status effective 05/01/22 - 05/01/23. ( Evaluation Report continues on LIC 809-C)

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SEASONS MEMORY CARE AT ROLLING HILLS	FACILITY NUMBER: 198320131
	VISIT DATE: 09/26/2022

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INFECTION CONTROL:
Infection control practices were observed by LPA at the facility. 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. The review of residents' COVID vaccinations was conducted for (9) staff members and (6) residents. The facility has provided CCLD with an approved Mitigation Plan and has submitted an Infection Control Plan 2022 to CCLD.

No Deficiencies were identified during this inspection visit.

An exit interview was conducted, and a copy of this report was provided to Tierre Thornton.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022

LIC809 (FAS) - (06/04)

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