<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602032
Report Date: 01/14/2023
Date Signed: 01/14/2023 02:18:13 PM

Document Has Been Signed on 01/14/2023 02:18 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:FINEST LIVING GUEST HOME IIFACILITY NUMBER:
198602032
ADMINISTRATOR:MEDINA, MARGARITAFACILITY TYPE:
740
ADDRESS:2104 W. 230TH STREETTELEPHONE:
(310) 533-7343
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 6CENSUS: 5DATE:
01/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:TERESA GUANLAOTIME COMPLETED:
01:00 PM
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 1/14/2023, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA Montoya conducted a risk assessment with Staff Teresa Guanlao who confirmed the facility is free of Covid-19 infection. LPA met with Staff Rodolfo Villanueva and Staff Benjamin Sayco upon arrival at the facility. Staff Teresa Guanlao arrived later and LPA explained the purpose of today’s visit.

The facility is licensed to operate for six (6) elderly residents ages 60 and above. The facility is approved for six (6) non ambulatory and hospice waiver for 6.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) bedrooms of which two (2) are private rooms and two (2) are shared rooms, 2 bathrooms, a living area, dining area, kitchen, and outside covered patio area.

LPA Montoya and Staff Guanlao toured the inside and outside of the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 116.1 degree Fahrenheit. A comfortable temperature was maintained in the facility.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. A fire extinguisher was charged and last serviced on 3/29/2022, smoke detectors and carbon monoxide were operable. A landline telephone 424-263-5410 was available and operable.

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2023
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 4
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: FINEST LIVING GUEST HOME II
FACILITY NUMBER: 198602032
VISIT DATE: 01/14/2023
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
Medications are locked & centrally stored in a cabinet near the entrance main door. The first aid kit has all required supplies.

During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed every staff was wearing a face covering. LPA observed 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.

Technical assistance was provided to Staff Guanlao.

Deficiencies are being cited based on LPA observation, interviews conducted and record review in accordance with the California Code of Regulations, Title 22, see LIC809D.

An exit interview was conducted, and Plans of Corrections were reviewed and developed with Staff Teresa Guanlao. A copy of this report and appeal rights were provided.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 01/14/2023 02:18 PM - It Cannot Be Edited


Created By: Lourdes Montoya On 01/14/2023 at 12:30 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
MONTEREY PARK, CA 91754

FACILITY NAME: FINEST LIVING GUEST HOME II
FACILITY NUMBER: 198602032

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above. LPA Montoya observed toxic and cleaning supplies in the facility readily accessible to residents with dementia. LPA observed a gallon of bleach in an unlocked closet adjacent to dining room where dryer and washer are stored. LPA also observed two plastic bottles of disinfecting sprays and a glass cleaner inside an unlocked closet where the water heater is stored readily accessible to residents with dementia. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/23/2023
Plan of Correction
1
2
3
4
The administrator moved the toxic and cleaning supplies to a closet not readily accessible to residents with dementia. The administrator shall review Section 87705 of Title 22 and conduct an in-service training to all staff. POC shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 01/14/2023 02:18 PM - It Cannot Be Edited


Created By: Lourdes Montoya On 01/14/2023 at 12:30 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
MONTEREY PARK, CA 91754

FACILITY NAME: FINEST LIVING GUEST HOME II
FACILITY NUMBER: 198602032

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above. Two residents (R1 & R2) who have dementia, do not have current annual medical assessment and reappraisal. R1's medical assesment is dated 7/1/2020 and reappraisal is dated 7/5/2020. R2's medical assessment is dated 12/3/2019 and reappraisal is dated 12/7/2019. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/23/2023
Plan of Correction
1
2
3
4
The administrator shall ensure residents with dementia shall have an annual medical assessment and reappraisal, both of which shall include a reassessment of the resident's dementia care needs. The administrator shall submit current medical assessment and reappraisal for R1 and R2 to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.
Type B
Section Cited
CCR
87705(d)
Care of Persons with Dementia
(d) In addition to requirements specified in Section 87303, Maintenance and Operation, safety modifications shall include, but not be limited to, inaccessibility of ranges, heaters, wood stoves, inserts, and other heating devices to residents with dementia.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview andrecord review, the licensee did not comply with the section cited above. LPA Montoya observed the water heater tank and stove are readily accessible to residents with dementia. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/18/2023
Plan of Correction
1
2
3
4
The administrator shall install a lock in the closet where the water heater tank is stored and shall cover the stove knobs to ensure these are not readily accessible to resident with dementia. POC shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the 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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2023


LIC809 (FAS) - (06/04)
Page: 4 of 4