198320214-2-14-2023-11-AS-FSHY-CP2UXN-20230214145836

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320214
Report Date: 02/14/2023
Date Signed: 02/14/2023 02:59:06 PM

Document Has Been Signed on 02/14/2023 02:59 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:	PACIFIC SUNRISE HOME 3		FACILITY NUMBER:	198320214
ADMINISTRATOR:	DANIEL, MONICA CENDANA		FACILITY TYPE:	740
ADDRESS:	28128 LOMO DRIVE		TELEPHONE:	(310) 938-6153
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90275
CAPACITY: 6		CENSUS: 5	DATE:	02/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Monica Daniel		TIME COMPLETED:	03:00 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	Licensing Program Analyst (LPA) Felisa Shirley and Licensing Program Manager(LPM) Stephanie CIfuentes conducted an unannounced Annual required and infection control visit to the above facility. LPA and LPM were met by caregiver Angel Maria Lemus and the purpose of today’s visit was explained. CCLD staff were allowed entrance to the facility. Administrator Monica Daniel later joined CCLD staff during the visit. The facility is a single-story structure located in a residential neighborhood. It consists (5) bedrooms, (3) full bathrooms, shaded back yard, front yard, laundry room and attached 2 car garage. LPA, LPM and caregiver Maria toured the physical plant. There were no obstructions on the premises or small bodies of water. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for client 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. Documents are posted as mandated. No firearms are stored at facility. Medications are stored, locked and inaccessible to residents. Ample supply of perishable and nonperishable food, linens and personal hygiene supplies. Hazardous toxins and/or sharp items are inaccessible to residents, (1) fire extinguisher was found in kitchen and is fully charged. The facility is in good repair. Continued on 809-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023

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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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: PACIFIC SUNRISE HOME 3	FACILITY NUMBER: 198320214
	VISIT DATE: 02/14/2023

NARRATIVE

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During the visit, LPA and LPM observed the facility infection control practices. LPA observed a sanitizing station at the facility entry & visitors and temperatures are logged and checked, sanitizer/soap, paper towels are in all the bathrooms and additional sanitation supplies are stored in the hall closet. LPA observed staff wearing masks and was told resident private rooms will be converted to isolation rooms (if needed). LPA observed trash cans with lids, cart for PPE’s and mitigation plan was posted. Fit testing was completed for staff and required postings are throughout the facility. Emergency contacts updated and posted; PPE's are enough for 30 days.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiencies:
-Bed in room 5 has a full bed rail, no hospice documentation was found for Resident 1(R1)

No technical Advisories (TA) issued.

An exit interview conducted with Monica Daniel, Administrator and a hard copy of report provided, citations and appeal rights were provided

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/14/2023 02:59 PM - It Cannot Be Edited

Created By: Felisa Shirley On 02/14/2023 at 02:03 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: PACIFIC SUNRISE HOME 3	FACILITY NUMBER: 198320214
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(5)(B)

Postural Supports

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above. LPA and LPM observed full bed rails in room of R1 and a review of medical records show that R1 is nor on hospice which poses a potential health and safety risk to persons in care.
	POC Due Date: 02/28/2023
	Plan of Correction
1 2 3 4	Administrator will remove full bed rails and obtain a prescription if half bed rails are put into place for resident. POC will be submitted to CCLD via fax by POC due date. On day of visit, administrator removed full bed rails and switched to half rails.

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:

Stephanie Cifuentes

LICENSING EVALUATOR NAME:

Felisa Shirley

LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023

LIC809 (FAS) - (06/04)

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