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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600150
Report Date: 06/23/2023
Date Signed: 06/23/2023 03:11:28 PM

Document Has Been Signed on 06/23/2023 03:11 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:RISE N'SHINE VILLAFACILITY NUMBER:
198600150
ADMINISTRATOR:ERLINDA HATMALFACILITY TYPE:
740
ADDRESS:3351 MCNAB AVE.TELEPHONE:
(562) 429-1359
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY: 5CENSUS: 4DATE:
06/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:58 PM
MET WITH:TIME COMPLETED:
03:11 PM
NARRATIVE
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On 6/23/2023, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required using the CARE Inspection Tool. LPA met with Erlinda Hatmal/Administrator. LPA explained the purpose of today’s visit. The facility is licensed to serve (5) residents ages 60 and above. (5) non-ambulatory and (0) bed ridden. Facility has a waiver for (1) hospice patient.

The facility consists of living room, dining room, kitchen, (3) resident bedrooms, (2) bathrooms (Bdrm #1 is shared and bdrm #2 and #3 are private). Staff living quarters for Administrator are located on right side of home. LPA Iniguez observed the facility to be free of odor.

LPA Iniguez toured the physical plant with administrator. There were no bodies of water or obstructions on the premises. A total of (2) 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 rooms: #1, #2, and #3 and smoke and carbon monoxide are all in operable conditions. The water temperature properly measured between 105°-120°F: Kitchen 116.7°F, Bathroom #1:113.8°F & Bathroom #2: 117.2°F. The room temperature ranged from 76F° – 78F°.

Evaluation Report Continues LIC 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2023
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: RISE N'SHINE VILLA
FACILITY NUMBER: 198600150
VISIT DATE: 06/23/2023
NARRATIVE
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LPA Iniguez observed the facility to be sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged and were operable. Working landline phones are available on-site. A review of (2) residents' service files (R1-R2) and (2) staff personnel files (S1-S2) and Medication Administration Records (MAR) were maintained in order. First Aid kit was checked. Last fire drill performed on 5/15/2023.

LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8.

See D pages for citations.

Exit interview conducted with Erlinda Hatmal/Administrator and a copy of the appeal rights were given at the time of the visit.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 06/23/2023 03:11 PM - It Cannot Be Edited


Created By: Alfonso Iniguez On 06/23/2023 at 02:55 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: RISE N'SHINE VILLA
FACILITY NUMBER: 198600150

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2023

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
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Based on observation the licensee did not comply with the section cited above in leaving cleaning supplies unlocked on bathroom sink which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/26/2023
Plan of Correction
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On 6/23/2023 Administrator removed cleaning products and locked them away. As part of POC Administrator will re-train staff and herself about locking cleaning supplies. Training will be sent to LPA 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 Alvarez
LICENSING EVALUATOR NAME:Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/23/2023 03:11 PM - It Cannot Be Edited


Created By: Alfonso Iniguez On 06/23/2023 at 02:55 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: RISE N'SHINE VILLA
FACILITY NUMBER: 198600150

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review the licensee did not comply with the section cited above in having a staff CPR card expired which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/07/2023
Plan of Correction
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Administrator will ensure all staff CPR are up to date and provide the expired CPR card 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 Alvarez
LICENSING EVALUATOR NAME:Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2023


LIC809 (FAS) - (06/04)
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