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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320133
Report Date: 02/15/2022
Date Signed: 02/15/2022 07:09:03 PM

Document Has Been Signed on 02/15/2022 07:09 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:WELCOME HOME IIFACILITY NUMBER:
198320133
ADMINISTRATOR:DIONISIO, ANTONIAFACILITY TYPE:
740
ADDRESS:3622 W. 225TH STTELEPHONE:
(310) 435-5820
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY: 6CENSUS: 6DATE:
02/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:02 AM
MET WITH:Administrator - Antonia DionisioTIME COMPLETED:
12:45 PM
NARRATIVE
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On 02/15/2022, Licensing Program Analyst (LPA) Don Senaha conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with Administrator Antonia Dionisio and explained the purpose of today’s visit. The facility is licensed to operate for six (6) elderly non-ambulatory residents ages 60 and above. Facility is approved for one (1) hospice.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident's rooms, two (2) bathrooms, two (2) living areas, dining area, kitchen and outside covered patio area with a table and chairs. There is an attached garage with access only through the garage door used for storage. The washer and dryer for laundry is located next to the kitchen area.

LPA and Administrator 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 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 water temperature measured between 112.8 F and 118.6 F in the bathrooms and kitchen. A comfortable temperature was maintained in the facility.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. 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. One (1) fire extinguisher were fully charged next to the kitchen, smoke detectors and carbon monoxide were operable. First aid kit is available where the medications are stored in the kitchen area.

Evaluation Report Continues on LIC 809-C
Eva M Alvarez
Don Senaha
DATE: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2022
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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Document Has Been Signed on 02/15/2022 07:09 PM - It Cannot Be Edited


Created By: Don Senaha On 02/15/2022 at 12:14 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: WELCOME HOME II
FACILITY NUMBER: 198320133

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. The licensee did not complete the Medication Administration Record for resident (R1) for January and February 2022 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/15/2022
Plan of Correction
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Licensee made corrections to the Medication Administration Record for resident (R1) and will read Title 22 section 87465 and send LPA an email indicating by end of day on 02/15/2022.
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Don Senaha
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2022


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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: WELCOME HOME II
FACILITY NUMBER: 198320133
VISIT DATE: 02/15/2022
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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. All mandated inspection control posters were posted.

One Advisory Note - Technical Assistance was issued, please see LIC9102-AN.

One deficiency was cited during the visit. See D page.

An exit interview was conducted, and a copy of this report was provided to Administrator Antonia Dionisio.
SUPERVISOR'S NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2022
LIC809 (FAS) - (06/04)
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