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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320133
Report Date: 03/26/2024
Date Signed: 03/26/2024 12:00:47 PM


Document Has Been Signed on 03/26/2024 12:00 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: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: 5DATE:
03/26/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:26 AM
MET WITH:Antonia Dionisio-AdministratorTIME COMPLETED:
12:00 PM
NARRATIVE
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On 3/26/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Antonia Dionisio/Administrator. LPA explained the purpose of today’s visit. The facility is licensed to serve (6) residents ages 60 and above. Of which (6) may be non-ambulatory. Approved hospice waiver for (1) in bedroom #3.

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, laundry room, and kitchen.


LPA toured the physical plant with staff. There were no bodies of water or obstructions on the premises. A total of (4) rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected the carbon monoxide detectors combo were in operable conditions. The water temperature properly measured :Kitchen 110.6°F, Bathroom #1:107.2°F and Bathroom #2:106.4°F.

Evaluation Report Continues LIC 809-C

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2024
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: WELCOME HOME II
FACILITY NUMBER: 198320133
VISIT DATE: 03/26/2024
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LPA Iniguez observed the facility to be clean, sanitary, and appropriately furnished at the time of the visit. Storage areas for personal hygiene were observed, cleaning agents, poisons, and sharps objects were locked 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 charged and were operable.

A review of (3) residents' service files, (2) staff personnel files were checked. (3) Medication Administration Records (MAR) were reviewed discrepancies were found. First AID kit was checked. Last fire disaster drill was on:3/4/2024.

LPA observed the facility's infection control practices. Liability insurance will be emailed to LPA. Facility Annual Fees Not Current. LPA gave to administrator PIN#602495 to pay fees online as soon as possible.

Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See details below:

-Documentation error on MARS for R#1.

-Expired CPR card for S#2.


An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Antonia Dionisio/Administrator.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/26/2024 12:00 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245


FACILITY NAME: WELCOME HOME II
FACILITY NUMBER: 198320133

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in not documenting given medications for R#1 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2024
Plan of Correction
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Licensee will ensure all medication documentation is consistent. As plan of correction, Licensee will re-train all staff on how to document correctly given medication on the MARS. Licensee will sent proof of training to LPA via email before POC due date.
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 AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 03/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 03/26/2024 12:00 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245


FACILITY NAME: WELCOME HOME II
FACILITY NUMBER: 198320133

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075
80075 Health Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in having an expired CPR card for S#2 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2024
Plan of Correction
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Licensee will ensure all staff will have a current CPR card on file. As plan of correction, Licensee will snet proof of current CPR card for S#2. Licensee will sent proof of correction to LPA via email before POC due date
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 03/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4