198602078-12-21-2023-11-AS-AINZ-CYQTV3-20231221140315

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602078
Report Date: 12/21/2023
Date Signed: 12/21/2023 02:03:20 PM

Document Has Been Signed on 12/21/2023 02:03 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:	CARING HOUSE		FACILITY NUMBER:	198602078
ADMINISTRATOR:	STEPHANY HARLOW		FACILITY TYPE:	740
ADDRESS:	2842 EL DORADO STREET		TELEPHONE:	(310) 796-6625
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90503
CAPACITY:	6	CENSUS: 5	DATE:	12/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:59 AM
MET WITH:	Joanna Franco-Administrator		TIME COMPLETED:	02:00 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 12/21/2023, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Joanna Franco /Administrator. LPA explained the purpose of today’s visit. The facility is licensed to serve (6) residents ages 60 and above. Facility has an approved hospice waiver for (6) patients and (6) approved for (6) bedridden.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: six (6) resident bedrooms, three (3) bathrooms, living area, dining area, kitchen, and outside covered patio area.

LPA Iniguez toured the physical plant with administrator. There were no bodies of water or obstructions on the premises. A total of (6) 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 properly measured between 105°-120°F: Kitchen 106.7°F, Bathroom #1:107.7°F, Bathroom #2:105.4°F.

Evaluation Report Continues LIC 809-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

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 3

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: CARING HOUSE	FACILITY NUMBER: 198602078
	VISIT DATE: 12/21/2023

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

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). First AID kit was checked. Last fire disaster drill was on: 10/20/2023.

LPA observed the facility's infection control practices. A copy of the liability insurance was provided to LPA during visit.

Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8. (See D page for details)

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

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 12/21/2023 02:03 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CARING HOUSE	FACILITY NUMBER: 198602078
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(d)(2)

Incidental Medical and Dental Care Services

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) The date and time of each contact with the physician, and the physician's directions, shall be documented and maintained in the resident's facility record. 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 in having the staff documenting the administration of medications in the MARS in a consitent way which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/03/2024
	Plan of Correction
1 2 3 4	Administrator will ensure all staff are documenting in the MARS in a consistent way. In addition, as plan of correction, administrator will re-train all staff about the importance of documenting in the MARS the administration of medications. Administrator will send proof of correction to LPA via email before 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: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3