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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600150
Report Date: 02/27/2024
Date Signed: 02/27/2024 11:57:00 AM


Document Has Been Signed on 02/27/2024 11:57 AM - 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245



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:
02/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Erlinda HatmalTIME COMPLETED:
12:20 PM
NARRATIVE
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On 02/27/24, Licensing Program Analyst (LPA) Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Administrator Erlinda Hatmal as the purpose of the visit was explained. The facility is licensed to serve (5) non-ambulatory residents ages 60 and above and has a hospice waiver with total care for (1). Current facility census is (4). Administrator was provided with annual fees info. Liability insurance is active.

The facility is a single-story structure located in a residential neighborhood and consists of the following: (3) resident bedrooms, (1) staff bedroom, (2) common bathrooms, (2) linen closets, living room, dinning area, kitchen a storage/laundry room and patio area with shade located in the front yard. There is an additional bedroom by the kitchen area that is occupies by homeowner. Client bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, shower was free of mold/mildew, and there are sufficient toiletries accessible to residents. The water temperature properly measured between 105-120 F.. A supply of perishable and non-perishable food was observed, toxins and knifes were stored and inaccessible to residents, no weapons nor bodies of water on the premises, exits and walkways are free of debris/hazards.

LPA conducted a records review of 2 staff records, 2 resident records, and 2 medication administration records, no discrepancies observed. Facility does not use a MAR. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire was conducted in December 2023 with the LBFD, 3 fire extinguisher fully charged, carbon monoxide and smoke detectors are interconnected and operational. A landline was observed.

Citation documented on 809D

Exit interview conducted with Administrator Erlinda Hatmal, appeal rights explained, and a copy of this report was provided.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 02/27/2024 11:57 AM - 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245


FACILITY NAME: RISE N'SHINE VILLA
FACILITY NUMBER: 198600150

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87632(a)(1-4)
87632 Hospice care waiver
In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department. To obtain this waiver the licensee shall submit a written request for a waiver to the Department on behalf of any residents who may request retention, and any future residents who may request acceptance, along with the provision of hospice services in the facility. The request shall include, but not be limited to the following:

Specification of the maximum number of terminally ill residents which the facility wants to have at any one time.

A statement by the licensee that they have read, Section 87633, Hospice Care for Terminally Ill Residents, this section and all other requirements within Chapter 8 of Title 22 of the California Code of Regulations governing Residential Care Facilities for the Elderly and that they will comply with these requirements.

A statement by the licensee that the terms and conditions of all hospice care plans which are designated as the responsibility of the licensee, or under the control of the licensee, shall be adhered to by the licensee.

A statement by the licensee that an agreement with the hospice agency will be entered into regarding the care plan for the terminally ill resident to be accepted and/or retained in the facility. The agreement with hospice shall design and provide for the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the licensee.

Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above as facility has an approved hospice waiver for (1), however facility currently has (3) residents receiving hispice services
which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/09/2024
Plan of Correction
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Licensee/Administrator will submit a hospice waiver form to increase hospce waiver from (1) to (3) to LPA by POC due date.

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: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2