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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601709
Report Date: 01/06/2024
Date Signed: 01/06/2024 03:04:23 PM


Document Has Been Signed on 01/06/2024 03:04 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245



FACILITY NAME:BLESSED TOUCH HOME CAREFACILITY NUMBER:
198601709
ADMINISTRATOR:MONTERROSO, ETHEL JANE O.FACILITY TYPE:
740
ADDRESS:1730 W. 1ST STREETTELEPHONE:
(310) 832-1960
CITY:SAN PEDROSTATE: CAZIP CODE:
90732
CAPACITY:6CENSUS: 4DATE:
01/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Ethel Monterroso/AdministratorTIME COMPLETED:
03:00 PM
NARRATIVE
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On 1/6/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Ethel Monterroso/Administrator. LPA explained the purpose of today’s visit. The facility is licensed to serve (6) non-ambulatory residents ages 60 and above. Of which (1) may be bedridden. Approved hospice waiver for (1).


The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident's rooms, two (2) common bathrooms, a living area, a dining area, a kitchen, and an outside patio area.

LPA Iniguez toured the physical plant with administrator. There were no bodies of water or obstructions on the premises. A total of (5) 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 the carbon monoxide detectors combo were in operable conditions. The water temperature measured: Kitchen 126.7°F, Bathroom #1:126.6°F, Bathroom #2:123.0°F.

Evaluation Report Continues LIC 809-C

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2024
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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: BLESSED TOUCH HOME CARE
FACILITY NUMBER: 198601709
VISIT DATE: 01/06/2024
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LPA Iniguez observed the facility to be clean, sanitary, and appropriately furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged and were operable. A review of (3) residents' service files, (3) staff personnel files and (3) Medication Administration Records (MAR) were reviewed. First AID kit was checked. Last fire disaster drill was on:10/4/2023. .

LPA observed the facility's infection control practices. A copy of the liability insurance will be email to LPA.

Civil Penalty rendered for repeated violation.



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


An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Ethel Monterroso /Administrator.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 01/06/2024 03:04 PM - 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: BLESSED TOUCH HOME CARE
FACILITY NUMBER: 198601709

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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 having hot water measure more that 120 F. degrees which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/08/2024
Plan of Correction
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Licensee will ensure faucets used by residents will deliver water less that 120 F. degrees. As plan of correction, licensee will create a log measuring every 2 hours measuring the hot water. Licensee will submitt this log to LPA as POC via email before POC due date.
Type A
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

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 posting a sign in kitchen sink that allerts users of hot water delivered which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/08/2024
Plan of Correction
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Licensee will ensure signs of hot water will be posted on the kitchen sink. As plan of correction, licensee will create a sign to post on the kitche sink and as proof of correction licensee will sent a picture of sign posted via email before 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: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 01/06/2024 03:04 PM - 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: BLESSED TOUCH HOME CARE
FACILITY NUMBER: 198601709

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and record review, the licensee did not comply with the section cited above in having a liability insurance on file since last year which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2024
Plan of Correction
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Licensee will ensure facility has a liability insurance active. In addition, licensee will sent proof of correction to LPA via email before POC due date.
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.

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 not having a TB test for one of the residents's files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/22/2024
Plan of Correction
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Licensee will ensure all residents have a current TB test on file. Licensee will submitt TB test as proof of correction to LPA vai email before 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: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4