198320230-2-14-2023-11-AS-DESA-CP2S72-20230214123649

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320230
Report Date: 02/14/2023
Date Signed: 02/14/2023 12:37:27 PM

Document Has Been Signed on 02/14/2023 12:37 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:	ACTIVE BOARD + CARE, LLC		FACILITY NUMBER:	198320230
ADMINISTRATOR:	MICHELSON, CANDICE		FACILITY TYPE:	740
ADDRESS:	3412 W. 187TH PL		TELEPHONE:	(310) 999-1937
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90504
CAPACITY:	6	CENSUS: 2	DATE:	02/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:09 AM
MET WITH:	Candice Michelson		TIME COMPLETED:	12:54 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 Manager (LPM) Ulysses Coronel and Licensing Program Analyst (LPAs) Antonine Richard and David Espana conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA was met by Administrator Michelson Candice and the purpose of today’s visit was explained. The facility is licensed to serve age range 60 and over. approved for 6 non-ambulatory, of which 1 may be bedridden. approved hospice waiver for 1. There are currently 2 residents in placement. 1 of 2 residents is non-ambulatory. The facility is a single story structure located in a residential neighborhood. It consists of the following: 3 bedrooms, 2 bathrooms, family room/dining room, kitchen, living room, shaded area, indoor and outdoor activity area, laundry room and detached garage. LPA and staff toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. 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 hot water temperature measured 116.2 F.A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. The kitchen was inspected and there is a enough perishable and non-perishable food available which is stored properly. Fire extinguisher was charged, smoke detectors and Carbon Monoxide were operable. During the visit, LPA observed the facility infection control practices. LPA observed staff and residents were wearing face coverings.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
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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Document Has Been Signed on 02/14/2023 12:37 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ACTIVE BOARD + CARE, LLC	FACILITY NUMBER: 198320230
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, LPA observed Unknown toxins present in the tool shed,and bleach, cleaning solutions in the garage and scissors in the dining table, kitchen drawers and desinfectent wipe in the linen closet.which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/15/2023
	Plan of Correction
1 2 3 4	The administrator agreed to have all toxins removed and stored were inaccessible to residents. Proof correction will be submited to LPA Antonine at antonine.richard@dss.ca.gov.

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: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
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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Document Has Been Signed on 02/14/2023 12:37 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ACTIVE BOARD + CARE, LLC	FACILITY NUMBER: 198320230
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited aboveLPA observed that the metal gate on the left side of the house was in disrepair which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/21/2023
	Plan of Correction
1 2 3 4	The administrator agreed to have the metal gate repaired. Proof correction will be submited to LPA Antonine at antonine.richard@dss.ca.gov.

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: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
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)

Page: 3 of 16

Document Has Been Signed on 02/14/2023 12:37 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ACTIVE BOARD + CARE, LLC	FACILITY NUMBER: 198320230
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(a)(3)(A)

Personal Accommodations and Services

(A) A bed for each resident, except that married couples may be provided with one appropriate sized bed. Each bed shall be equipped with good springs, a clean and comfortable mattress, available pillow(s) and lightweight warm bedding. Fillings and covers for mattresses and pillows shall be flame retardant. Rubber sheeting shall be provided when necessary. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on obervation and interview the licensee did not comply with the section cited above during today LPA observed a total of 4 beds present during todays visit instead of 6 which is a violation iof Title 22 Regulation.
	POC Due Date: 02/21/2023
	Plan of Correction
1 2 3 4	The administrator agreed to place additonal beds in bedrooms 1 and 2. The administrator agreed to submit a request to reduce capacity prior removing said beds. Proof correction will be submited to LPA Antonine at antonine.richard@dss.ca.gov.

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: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
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)

Page: 15 of 16

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: ACTIVE BOARD + CARE, LLC	FACILITY NUMBER: 198320230
	VISIT DATE: 02/14/2023

NARRATIVE

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LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

During today’s visit there were deficiencies observed. LPA did not observe observed the facilities 30-day supply of Personal Protective Equipment (PPE). LPA did not observe screening protocols for visitors, staff and residents. Storage areas for cleaning, toxins, and sharps were accessible to clients. LPA Observe the metal gate on the left side of the house is an disrepair. LPA did not observe required COVID-19 related postings throughout the facility. LPA observed only 4 beds present at the facility.

Exit interview held, plans of corrections were developed. A copy of the report and appeals rights was provided to Candice Michelson, administrator.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
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)

Page: 16 of 16