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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601887
Report Date: 09/12/2024
Date Signed: 09/12/2024 06:32:23 PM


Document Has Been Signed on 09/12/2024 06:32 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:VELEZ CARE HOMEFACILITY NUMBER:
198601887
ADMINISTRATOR:CHILLY LYN NAVARROFACILITY TYPE:
740
ADDRESS:2120 VELEZ DRIVETELEPHONE:
(213) 880-1629
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY:4CENSUS: 4DATE:
09/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:09 AM
MET WITH:Josefina Guiao-House ManagerTIME COMPLETED:
01:41 PM
NARRATIVE
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On 9/12/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Josefina Guiao /House Manager. LPA explained the purpose of today’s visit. The facility is licensed to serve (4) elderly adults ages 60 and above, of which (4) can be non-ambulatory. The facility has an approved hospice waiver for (2). The clients are from Harbor Regional Center. (1) Restricted Health Care Conditions, and (1) utilizes postural support or protective devices. Staff to client ratio is (1:2).

The facility is a single-story structure located in a residential neighborhood. It consists of four (4) bedrooms, two (2) full bathrooms, shaded back yard, front yard, laundry room, family room, living room/office, kitchen, empty pool covered, sun room and attached two (2) car garage.



LPA Iniguez and the house manager toured the physical plant. There are bodies of water but covered no obstructions on the premises. LPA inspected a total of (4) bedrooms and (2) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were found to be within Title 22 regulations and were operational. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 108.5°F to 115.2°F, and the room temperature ranged from 76°F to 78°F.

The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024
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 5


Document Has Been Signed on 09/12/2024 06:32 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: VELEZ CARE HOME
FACILITY NUMBER: 198601887

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85066(b)(1-4)
85066 Personnel Records (b) A dated employee time schedule shall be developed at least monthly, shall be displayed conveniently for employee reference and shall contain the following information for each employee:

(1) Name.

(2) Job title.

(3) Hours of work.

(4) Days off.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in not having a LIC 500 available during annual inspection which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2024
Plan of Correction
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Licensee will ensure a LIC 500 is available at the facility at all times. As part of plan of correction (POC) licensee will send copy of LIC 500 to LPA Iniguez 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 AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024
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: VELEZ CARE HOME
FACILITY NUMBER: 198601887
VISIT DATE: 09/12/2024
NARRATIVE
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During the visit, LPA Iniguez observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drills were conducted on 8/24/24.

A review of (3) residents' service files and (3) staff personnel files was conducted. LPA reviewed (3) Medication Administration Records (MARs) and found no discrepancies.

LPA observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. A copy of liability insurance was emailed to LPA. Facility Annual Fees are not current, LPA Iniguez provided PIN #583489 to House Manager.

Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See details below:

-Staff separated from facility in Guardian on 5/31/24.

-Expired CPR card for DSP.

-No LIC 500 available at the time of annual visit.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. *


An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Josefina Guiao /House Manager.

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

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/12/2024 06:32 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: VELEZ CARE HOME
FACILITY NUMBER: 198601887

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in not having S#1 associated at the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/13/2024
Plan of Correction
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Licensee will ensure all staff are associated at the faclity at all times. As part of Plan of Correction (POC), licensee will associate S#1 in Guardian and sent proof of association 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 AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 09/12/2024 06:32 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: VELEZ CARE HOME
FACILITY NUMBER: 198601887

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in having an expired CPR card from S#3 on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2024
Plan of Correction
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Licensee will ensure all staff have an active CPR card at all times. As part of Plan of Correction (POC), licensee will sent new CPR card from S#3 to LPA Iniguez 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 AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5