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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601457
Report Date: 03/23/2023
Date Signed: 03/23/2023 04:17:00 PM

Document Has Been Signed on 03/23/2023 04:17 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:LEE ADULT HOMEFACILITY NUMBER:
198601457
ADMINISTRATOR:ANDREW J. LEEFACILITY TYPE:
735
ADDRESS:20121 GREVILLEA AVENUETELEPHONE:
3108779282
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY: 6CENSUS: 4DATE:
03/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:27 AM
MET WITH:Quianna Davis, AdministratorTIME COMPLETED:
04:43 PM
NARRATIVE
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On March 23, 2019 at 8:27 AM, Licensing Program Analyst (LPA) Mario Leon conducted an unannounced Annual Required Inspection and met with Administrator Quianna Davis (A1) and Facility Manager Israel Diaz (FM1). Three (3) clients and two (2) staff were present in the facility during this inspection.

The Facility is licensed to serve up to 6 ambulatory clients ages 18-59. The facility handles resident debit card income via Trust Management Services, see LIC811.

The home consists of one (1) music therapy room, four (4) resident rooms, two (2) restrooms, kitchen, one (1) dining room, one (1) living room, one (1) staff office, an attached garage with laundry/pantry room and backyard with cabana.

A1 accompanied LPA throughout physical plant tour, including the inside and outside 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. There are no security bars or weapons on the premises.

Resident bathrooms were checked. Toilets and water faucets worked properly, showers were free of mold/mildew and a non-skid mat was in place. Resident toiletries and personal hygiene supplies were adequately stocked. All bath towels are currently soiled.

LPA tested the hot water temperature in Kitchen and it measured at 108.3 F.

Common areas were clean and clear of hazards, doorways were free of obstructions. Documents are posted as mandated.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE: DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2023
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: LEE ADULT HOME
FACILITY NUMBER: 198601457
VISIT DATE: 03/23/2023
NARRATIVE
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LPA toured the kitchen area and garage areas and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in the laundry/pantry room, inaccessible to clients. First Aid kit was available, with handbook yet missing tweezers. Fire extinguishers were observed, one near the stove in the kitchen area and one in the staff office room last inspected 3/22/23

LPA tested both carbon monoxide detectors (one (1) located in kitchen, one (1) located in living room) and hard-wired smoke detector unit located in the bedroom hallway area. All devices were functional. LPA observed that all 5 bedrooms, garage and both hallways are equipped with smoke detectors. The last fire drill conducted was on 2/27/23.

LPA reviewed 4 clients records and observed all client records were complete, except for client #4's TB test results although test was completed 12/08/22.

There were two (2) technical violations cited . See LIC-9102AN.

There were four (4) Deficiencies cited based on LPA's observation and record review. See LIC-809D.

An exit interview was conducted, Plans of Corrections were reviewed and developed with the Licensee Quianna Davis. A copy of this report and appeal rights were provided and left with Administrator Quianna Davis.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 03/23/2023 04:17 PM - It Cannot Be Edited


Created By: Mario Leon On 03/23/2023 at 03:22 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: LEE ADULT HOME
FACILITY NUMBER: 198601457

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(g)
Fixtures, Furniture, Equipment, and Supplies
(g) The licensee shall provide linens of various kinds necessary to meet the program of services being offered by the facility and the requirements specified in Chapters 2 through 7.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above in lacking sufficient bath towels which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/24/2023
Plan of Correction
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LPA and Administrator Quianna Davis have agreed that facility will send media evidence (photo), via email, of sufficient bath linens to Mario.Leon@DSS.CA.GOV on, or prior to, the above mentioned POC due date which has been listed as 3/24/23.
Type A
Section Cited
CCR
85088(d)
Fixtures, Furniture, Equipment, and Supplies
(d) If the facility operates it own laundry, necessary supplies shall be available and equipment shall be maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above in that clothes dryer is currently missing which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/07/2023
Plan of Correction
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LPA and Administrator Quianna Davis have agreed that facility will send media evidence (photo / video), via email, of the new clothes dryer to Mario.Leon@DSS.CA.GOV on, or prior to, the above mentioned POC due date which has been listed as 4/07/23.
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
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 03/23/2023 04:17 PM - It Cannot Be Edited


Created By: Mario Leon On 03/23/2023 at 03:22 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: LEE ADULT HOME
FACILITY NUMBER: 198601457

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80069(c)(1)
Client Medical Assessments
(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on LPA's record review, the licensee did not comply with the section cited above in the lack of Tuberculosis testing results which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2023
Plan of Correction
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LPA and Administrator Quianna Davis have agreed that facility will send media evidence (photo / PDF), via email, of test results on medical assessment record for client #4 (Client number is based on facilities' MAR) to Mario.Leon@DSS.CA.GOV on, or prior to, the above mentioned POC due date which has been listed as 3/31/23.
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:Ulysses Coronel
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023


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Page: 4 of 7
Document Has Been Signed on 03/23/2023 04:17 PM - It Cannot Be Edited


Created By: Mario Leon On 03/23/2023 at 04:06 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: LEE ADULT HOME
FACILITY NUMBER: 198601457

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(g)
Health-Related Services
(g) If the facility has no medical unit on the grounds, first aid supplies shall be maintained and be readily available in a central location in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above in the lack of necessary tweezers being present which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/24/2023
Plan of Correction
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LPA and Administrator Quianna Davis have agreed that facility will send media evidence (photo), via email, of one (1) pair of tweezers within the first aid kit to Mario.Leon@DSS.CA.GOV on, or prior to, the above mentioned POC due date which has been listed as 3/24/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023


LIC809 (FAS) - (06/04)
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