198320218-10-3-2023-11-AS-RCLD-CW9VZ2-20231003165200

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320218
Report Date: 10/03/2023
Date Signed: 10/03/2023 04:52:20 PM

Document Has Been Signed on 10/03/2023 04:52 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	GRANDVIEW GUEST HOME		FACILITY NUMBER:	198320218
ADMINISTRATOR:	SANTOS, JENNICE-RAE RUTA		FACILITY TYPE:	740
ADDRESS:	2444 235TH ST		TELEPHONE:	(310) 782-5045
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90501
CAPACITY:	6	CENSUS: 5	DATE:	10/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:51 PM
MET WITH:	Coty Cabral, President		TIME COMPLETED:	05:00 PM

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On 10/032023 at 2:51 PM, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced Required – Annual Inspection and met with Coty Cabral, President. Five (5) residents and three (3) staff were present during this inspection.

Facility is licensed to serve six (6) non-ambulatory residents, one (1) may be bedridden. The facility also has an approved hospice waiver for three (3) residents. The Annual Licensing Fees are current.

The home consists of 1 floor level with: 4 resident rooms (Room 2 is designated for bedridden), 2 restrooms, kitchen, dining room, living room, and garage.

The President accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards.

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.

Common areas were clean and clear of hazards, doorways were free of obstructions.

LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxics were kept in locked storage cabinet. First Aid kit was available.

5 resident records were reviewed and, 5 out of 5 client records had Admission Agreements, Medical Assessments, Pre-appraisals (or Reappraisals) and/or Needs & Services Plans. 2 resident medication and MAR were reviewed.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GRANDVIEW GUEST HOME	FACILITY NUMBER: 198320218
	VISIT DATE: 10/03/2023

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During record review, LPA did not observe an infection control plan nor an indication whether the emergency and disaster plan was reviewed or updated. Technical assistance was provided.

Due to time constraints a Case Management - Annual Continuation visit will be conducted.

A copy of this report was provided to Coty Cabral, President.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

LIC809 (FAS) - (06/04)

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