198320364-8-15-2023-11-AS-RCLD-CUQQYR-20230815123534

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320364
Report Date: 08/15/2023
Date Signed: 08/15/2023 12:36:20 PM

Document Has Been Signed on 08/15/2023 12:36 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:	THRIVE BOUTIQUE SENIOR LIVING - REDONDO BEACH		FACILITY NUMBER:	198320364
ADMINISTRATOR:	NEMETH, JOHN		FACILITY TYPE:	740
ADDRESS:	2011 GRAHAM AVENUE		TELEPHONE:	(310) 493-1221
CITY:	REDONDO BEACH	STATE: CA	ZIP CODE:	90278
CAPACITY:	6	CENSUS: 0	DATE:	08/15/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:56 AM
MET WITH:	John Nemeth		TIME COMPLETED:	12:35 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 (LPA), Regina Cloyd, conducted an announced visit to the facility for purpose of a prelicensing evaluation. Today’s pre-licensing evaluation was conducted with John Nemeth, CEO & Administrator. An application was submitted to CCLD on 10/22/2022, for Initial license for a Residential Care Facility for the Elderly to serve the Elderly for 60 years and older. The requested capacity is for (6), (6) non-ambulatory of which (0) may be bedridden. Structure: Facility is a (6) bedroom, (5) bathroom, two story house with an (1) elevator. The facility is a grey stucco structure with 1 Office/Laundry, 1 Kitchen and Dining area, and 1 living room. The home has a fire place in the dining room with a metal screen cover, and is inaccessible to clients. There is a 1 Patio/Courtyard and 1 Upper Patio on the premises. The client bedrooms are spacious and will easily accommodate the client's furnishings. Bedrooms Residents: Bedrooms are for (6) non-ambulatory clients. Bedroom has one bed, one chair, one night stand, and adequate overhead lighting. There are closets in each resident's room.Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Bathrooms: All bathrooms have a working toilet, wash basin, and shower. Fire Extinguishers: There are three fully charged fire extinguishers downstairs and one upstairs.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

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: THRIVE BOUTIQUE SENIOR LIVING - REDONDO BEACH	FACILITY NUMBER: 198320364
	VISIT DATE: 08/15/2023

NARRATIVE

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Food Service:
Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in a locked drawer next to the sink. Dishwasher in kitchen properly installed.

Smoke Detectors:

Carbon monoxide and smoke detector combination units located in common areas are Electrical & connected & working.

Toxins:
Locked and inaccessible.

Appliances:
Stove burners, oven, microwave, washer, and dryer working. There is one refrigerators in the home which has a measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezer is at (0) zero degrees Fahrenheit.

Water Temperature:
Hot water tested at 107 and 120 degrees.

Medications, First-Aid Kit & Book:
A first aid kit has been inspected which has at least the following: tweezers, scissors, antiseptic, bandages, and gauze, available for staff use but inaccessible to clients.

Clients & Staff Files:
Records of staff and clients will be stored in a locked cabinet in the office.

Reading Material, Games, Equipment & Materials:
The facility has activities and other recreational materials for the client's use, commensurate with the plan of operation.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

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: THRIVE BOUTIQUE SENIOR LIVING - REDONDO BEACH	FACILITY NUMBER: 198320364
	VISIT DATE: 08/15/2023

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Pool/Jacuzzi & Pets: None.

Fire clearance:
Rooms approved for 6 non-ambulatory and 0 bedridden, was approved on 04/12/2023.

Pre-licensing Checklist:
Completed by licensee and reviewed by LPM and LPA.

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance.

During the prelicensing inspection certain items were observed which do not comply with applicable laws and regulations; the following items must be corrected and proof of correction shall be submitted to the CCLD office to the attention of LPA Regina Cloyd (regina.cloys@dss.ca.gov) by 08/31/2023. If additional time is required to complete noted items to correct, then the applicant will request an extension in writing prior to the due date. Some items may require a follow up inspection for verification of correction.

1. All outdoor passageways needs to be free off obstructions.

2. personal rights, nondiscrimination notice, and complaint information needs to be prominently posted in areas accessible to residents, representatives, and the public.

3.The PUB 475 poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.

4. The visitation policy needs to be prominently posted i areas accessible to residents, representatives,
and the public.

5. The facility need to have a shaded area to accommodate outdoor activities.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

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: THRIVE BOUTIQUE SENIOR LIVING - REDONDO BEACH	FACILITY NUMBER: 198320364
	VISIT DATE: 08/15/2023

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6. The facility needs to have a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency.

7 The first aid kit shall contain a Thermometer.

An exit interview was conducted and a copy of this report has been furnished to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

LIC809 (FAS) - (06/04)

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