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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601458
Report Date: 04/19/2022
Date Signed: 04/20/2022 09:56:46 AM

Document Has Been Signed on 04/20/2022 09:56 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME:LEE ADULT HOME IIFACILITY NUMBER:
198601458
ADMINISTRATOR:ANDREW J. LEEFACILITY TYPE:
735
ADDRESS:21140 DENKERTELEPHONE:
(310) 877-9282
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 4CENSUS: 4DATE:
04/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:QUIANNA DAVISTIME COMPLETED:
02:15 PM
NARRATIVE
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On 4/19/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced annual required inspection with a primary focus on Infection Control measures using the new CARE Inspection Tool.

Upon arriving at the facility, LPA called Administrator Andrew Lee and conducted a risk assessment. LPA met with Assistant Administrator Quinna Davis and explained the purpose of this visit. LPA was granted access and allowed to enter the facility to conduct an inspection. The facility is licensed to serve four (4) ambulatory, clients ages 18-59. The facility’s annual fees are current during today’s visit. Clients are referred by the Harbor Regional Center.

LPA toured the single-story facility with Davis. The facility consists of four (4) client bedrooms, two (2) bathrooms, kitchen, dining area, living room, locked washer/dryer/storage room, garage, office and backyard patio.

The kitchen was inspected and there is at least a one week supply of nonperishable and two day supply of perishable foods. The facility is maintained at a comfortable temperature. Hot water temperature measures at 110.2 degrees Fahrenheit. There are working lights in each room to ensure safety and comfort for all clients in the facility. All outdoor and indoor passageways were free of obstructions. The clients have clean linen which includes blankets/bedspreads, top and bottom sheets, pillow cases, and mattress pads. First aid kit had the required items. The facility has a written emergency disaster plan located in the office area. This facility has two operable carbon monoxide detectors located in the dining area and living room. There are no pools or bodies of water on the premises. There are no firearms on the premises and other dangerous weapons. The last facility fire drill was on 3/22/2022. Centrally stored medications are locked in a cabinet located in the kitchen.

Report continued in LIC 809-C

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2022
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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME: LEE ADULT HOME II
FACILITY NUMBER: 198601458
VISIT DATE: 04/19/2022
NARRATIVE
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During the visit, LPA observed the following to be in compliance: facility's infection control practices; screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms; every staff was wearing a face covering; the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has a Mitigation Plan Report approved by CCLD.

Deficiencies were cited.

Exit interview conducted and a copy of this report and appeal rights were provided to Assistant Administrator Quinna Davis

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/20/2022 09:56 AM - It Cannot Be Edited


Created By: Lourdes Montoya On 04/19/2022 at 01:30 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
MONTERY PARK, CA 91754

FACILITY NAME: LEE ADULT HOME II
FACILITY NUMBER: 198601458

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that 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 LPA's observation, the licensee did not comply with the section cited above. LPA observed a Lysol spray can in the clients' recreation room. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/20/2022
Plan of Correction
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Administrator removed the Lysol spray can immediately after LPA noticed the Lysol. This deficiency has been corrected at the time of visit.
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:Angela J Kendrick
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/20/2022 09:56 AM - It Cannot Be Edited


Created By: Lourdes Montoya On 04/19/2022 at 01:47 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
MONTERY PARK, CA 91754

FACILITY NAME: LEE ADULT HOME II
FACILITY NUMBER: 198601458

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation and interview, the licensee did not comply with the section cited above. LPA observed the floor in the living room, kitchen, dining area, hallways, client bedrooms, bathrooms and recreation room is dirty. LPA observed food crumbs on the floor and the refrigerator is dirty as well. LPA observed a smoke detector in the dining area is not operable. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2022
Plan of Correction
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Administrator agreed to clean the floor all over the facility by the POC due date. Asst. Administrator Davis agreed to replace the smoke detector in the dining area later today. Davis will submit a proof of POC to lourdes.montoya@dss.da gov by the 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:Angela J Kendrick
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022


LIC809 (FAS) - (06/04)
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