198602022-3-1-2024-11-AS-JCAN-D2WQSQ-20240229112556

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602022
Report Date: 02/29/2024
Date Signed: 03/01/2024 08:41:07 AM

Document Has Been Signed on 03/01/2024 08:41 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:	HALLDALE MANOR		FACILITY NUMBER:	198602022
ADMINISTRATOR:	BUSTOS, GLENDA		FACILITY TYPE:	740
ADDRESS:	23438 HALLDALE AVENUE		TELEPHONE:	(310) 533-7364
CITY:	HARBOR CITY	STATE: CA	ZIP CODE:	90710
CAPACITY:	6	CENSUS: 5	DATE:	02/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	STAFF VIRGINIA ROMANO		TIME COMPLETED:	11:30 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 02/29/2024 at 09:00 AM, Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced annual inspection visit at the Halldale Manor Facility. LPA Calderon was allowed entry into the facility by Staff Virginia Romano. Staff Virginia Romano asked infection control questions and took LPA Calderon temperature prior to entrance into the facility. The facility is licensed to operate for (6) non-ambulatory elderly adults of which (1) may be bedridden ages 60 and above. Currently, the facility has (5) residents and (1) in hospice care. The facility is approved for (2) hospice residents. LPA Calderon explained to Staff Virginia Romano, the purpose of the one year Annual Inspection visit, and escorted LPA Calderon on a tour of the entire inside and outside facility grounds. As part of the inspection, LPA Calderon reviewed: Four (4) client service records, four (4) client medication records, two (2) staff records, and inspected the inside facility and outside grounds. LPA Calderon interviewed four (4) clients and two (2) staff members for visit. The facilities’ last fire drill was conducted on 01/08/2024. The one story residential home consists of four (4) client bedrooms, two (2) client bathrooms, living room, dining room, kitchen, staff room, office area, attached garage with washer and dryer/ storage area, backyard with table and chairs. No weapons are stored in the premises. Kitchen was inspected and observed to be clean and operational. A two day supply perishable and seven day supply of non-perishable foods are present in the facility. Emergency Water Storage is in the garage and kitchen area.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

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 3

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: HALLDALE MANOR	FACILITY NUMBER: 198602022
	VISIT DATE: 02/29/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA Calderon observed that all facility rooms are clean and in good repair. A comfortable temperature was observed, and the facility has central air and heating. LPA Calderon observed the following during inspection of client’s rooms: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, LPA Calderon observed fully stocked closet with bedding, towels, and toiletries supplies. Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. LPA Calderon observed bathrooms were found to be within Title 22 regulation. Bathroom #1 hot water temperature properly measured at 110 degrees Fahrenheit, and bathroom #2 hot water temperature properly measured at 109 degrees Fahrenheit. Kitchen hot water temperature properly measured at 112 degrees Fahrenheit. Facility one (1) Carbon Monoxide and six (6) Smoke Detectors hard wired and connected were tested and are working properly. The facility one (2) Fire Extinguishers was checked and found to be fully charged and accessible. All exit doors in the facility have alarm systems. All toxins and knifes are locked/secured and inaccessible to clients. Medications are centrally stored and in a locked storage cabinet. Facility first aid kit is fully stocked with manual was checked and in order. A working landline phone was operational. Outside grounds were toured and no bodies of water were observed. All Exits/ Walkways around the home were free of debris and hazards. Outside patio accessible to clients. Four (4) client files were reviewed and found to be complete. LPA Calderon reviewed four (4) resident medications and they were all found to be administered according to doctor's orders. Two (2) staff files were checked and have the required documents. LPA Calderon noted the Administrator Evangeline A Agatep Certification # 6021587740 expiration date of 11/08/2024 was valid at time of visit. The facility does NOT handle client's money/cash resources and a NO Surety bond is needed. Commercial General Liability Policy #001173172 policy period from 05/25/2023 to 05/25/2024 underwritten by James River Insurance Company, coverage 1,000,000/3,000,000 is valid at time of inspection. Administrator Evangeline A Agatep to email LPA Calderon a full copy of the commercial insurance policy including all endorsements no later than 03/10/2024. All the required documents are posted in the facility in a clearly visible area.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: HALLDALE MANOR	FACILITY NUMBER: 198602022
	VISIT DATE: 02/29/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and clients, sanitizing stations (Located in common areas and restrooms). LPA observed staff and clients were NOT wearing face coverings. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

LPA Calderon advised the Staff Virginia Romano to continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA Calderon did not observe deficiencies therefore no citations were issued at this time. Annual Licensing Fee is CURRENT. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Staff Virginia Romano.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3